Whistleblowers may report health care and pharmaceutical fraud against the government.
State and federal governments pay billions each year in healthcare costs through several government healthcare programs, including Medicare and Medicaid. Government spending on healthcare touches nearly every area of medicine including hospitals, doctor’s offices, labs, hospices, and nursing homes.
Due to their prevalence and size, government healthcare programs are frequent targets of fraud.
Health care fraud involving patient services can take many forms, including:
- Billing for services not performed.
- Billing for unnecessary services.
- Billing for services in violation of coverage policies, such as national coverage determinations (NCDs) and local coverage determinations (LCDs).
- Upcoding, i.e., charging for a more expensive service or test than what actually took place.
- Paying kickbacks to service providers for referring patients or performing services in violation of the Anti-Kickback Statute and/or Stark Law.
- Reporting fraudulent and/or inflated cost bases for services to the government.
- Billing for services provided by unlicensed providers or performed at unaccredited locations. Click here for example
Whistleblowers typically report fraud against the government. However, two states (California and Illinois) also allow whistleblowers to pursue lawsuits based on fraud against private insurance companies.
California has enacted the California Insurance Fraud Prevention Act, while Illinois has enacted the Illinois Insurance Claims Fraud Prevention Act. Both laws authorize whistleblower to file qui tam lawsuits against companies or individuals that have defrauded private insurance companies. If the lawsuits are successful, the whistleblower is entitled to retain a portion of the recovery.
The types of misconduct that are prohibited by the California and Illinois laws are similar to type of healthcare fraud committed against the government.
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