What is Billing Fraud ?
Billing fraud comes in many shapes and sizes, but, at its core, it involves a healthcare provider submitting claims and receiving payment for procedures and services when the provider is in fact not entitled to such payment. Billing fraud affects every type of healthcare provider, including hospitals, nursing homes, independent physicians, and pharmacies, to name a few. The False Claims Act permits whistleblowers to sue providers who defraud Government insurance programs, such as Medicare, Medicaid, and TRICARE. If the provider is located in California or Illinois, whistleblowers can also sue them for committing fraud against private insurance carriers.
Billing for Services Not Rendered or Not Medically Necessary
The most straightforward type of billing fraud occurs when a provider bills patients’ insurance for procedures that were not performed or not medically necessary. For instance, a doctor may claim to have seen a patient in person even though the patient never showed up for the appointment. Alternatively, the doctor may perform ultrasounds and x-rays reflexively on every patient, regardless of medical need. If either provider then billed those claims to Medicare or Medicaid, they would be committing fraud.
For a related type of Medicare fraud, see our article on Upcoding.
The second type of billing fraud is called false certification. To qualify for payment from Government insurance programs, the provider must certify compliance with all applicable laws and regulations, such as state licensing/accreditation requirements and the Medicare and Medicaid conditions of participation. Each type of provider has different requirements to be qualified to bill for services, such as:
• Hospitals must be properly licensed by their states and/or accredited by an accreditation agency.
• Clinical labs must be licensed under the Federal CLIA regulations.
• Outpatient and ambulatory surgery centers must strictly follow the conditions of coverage in the Medicare regulations.
If providers certify compliance with these requirements when they are not in compliance, they may be liable under the False Claims Act.
However, one caveat with false certification claims is that a whistleblower must be able to demonstrate that any alleged violation, if known by the insurance carrier, would have resulted in the denial of payment. Generally, insurance carriers will give providers a chance to cure violations before terminating payments. Thus, a whistleblower will have to demonstrate either that the provider was unable to cure the violations, or that the violations were so serious that insurance carriers terminated payments immediately, without an opportunity to cure them.
Reporting Billing Fraud Healthcare the Right Way
Whistleblowers have over the years helped the government recover billions of dollars by reporting healthcare misconduct like Billing fraud.
You as an insider witnessing healthcare billing fraud at the hospital, physicians office, nursing home or any other healthcare service provider, aid with uncovering those who undermine the system and put lives at risk. If you blow the whistle the right way, you can provide an important public service and win a whistleblower award that’s a percentage of the potentially millions of dollars recovered by the government. If you blow the whistle the wrong way, your case could be over before it begins. Contact us at Brown, LLC today to discuss your case confidentially at (877) 561- 0000.
100 Million Dollar Settlement Fund for Women Injured by a New Birth Control Product
Jason T. Brown was the first attorney in the country to file a battery of cases on behalf of women who sustained blood clots, such as deep vein thrombosis, pulmonary embolisms, strokes and death from a new Birth control Product. Jason T. Brown’s prior firm was on the PSC (Plaintiff Steering Committee) and served as liaison counsel in the state mass tort action. The firm is no longer accepting new cases.
Tens of Millions in Settlements for Mass Tort Injuries and Class Actions
$7 Million Plus Settlement for Consumer Fraud
$7 Million Dollar Commercial Litigation Settlement
Millions in Settlements for Women Injured by New Generation Hormonal Product
Women who sustained blood clots from a new Generation Hormonal Product received and continue to receive compensation for their injuries. Compensable injuries include Pulmonary Embolisms (PE), Deep-Vein Thrombosis (DVT), Strokes and Death. The firm is still investigating and accepting cases.
Nationwide $3.5 Million Settlement for Wage & Hour Class Action Case
Case brought on behalf of at home call center workers who were not paid for all their time worked including boot up time, technical time and other time. Workers were told by the company that boot up time which lasted 15 minutes or more was not paid because it was considered their commute to work. Fair Labor Standards Act (FLSA).
$3.2 Million Settlement for Wage & Hour Class Action Case
Case brought on behalf of workers who were misclassified as salaried exempt from overtime. The employer led employees to believe that they had to work unlimited hours over 40 without overtime compensation even though based on their job duties it was alleged they were entitled to overtime pay.
$2.4 Million Dollar Settlement for Wage & Hour Class Action
Lawsuit was brought as a class action on behalf of workers who worked in excess of 40 hours a week and were not paid overtime. The employer was forcing them to work “off the clock” for those hours and failed to pay proper overtime compensation.
$2 Million Dollar Settlement for False Claims Act (Whistleblower Case)
“$2 Million Dollar False Claims Act (FCA) Settlement – Unnecessary Services”
A case against GenomeDx was brought alleging violations of the False Claims Act (FCA) and the California Insurance Claims Fraud Prevention Act regarding unnecessary services such as the testing of tissues that did not need to be tested. The case resulted in a $350,000 whistleblower award.
$2 Million Dollar Settlement for Truck Accident Victim
Our firm was Of Counsel to a serious truck accident case involving a trucking accident with multiple injuries.
Nationwide $1.3 Million Judgment against Future Income Payments and Scott Kohn for Consumer Fraud
Scott Kohn and Future Income Payments conspired to defraud veterans out of their hard earned pensions by offering them loans at loanshark rates and claiming it was a “purchase” not a loan.
$1.7 Million Dollar Settlement for Wage & Hour Case
Misclassified employees under the FLSA were not paid overtime for hours worked in excess of 40. Due to a confidentiality agreement specific details are intentionally omitted.
Judgment with Maximum Damages for Employment Litigation
Judgment for misclassification under the FLSA including maximum damages under State and Federal Laws, plus an incentive fee for the lead plaintiff with attorney fees paid separately. The case involved a worker who was paid a day rate regardless of the amount of hours worked per day and per week.
Class Action Jury Trial
Workers alleged that they were misclassified according to their job duties. The Defendant claimed an administrative exemption under the FLSA and state law. Misclassification cases under the FLSA are the cases most often tried due to non-monetary considerations. Jury Trial lasted three weeks. Settlement offered in lieu of appeal.
Acquittal at Trial
Despite videotaped evidence that the prosecutor alleged incriminated the defendant, Mr. Brown was able to obtain an acquittal at trial for his client. Please note, that while we, the Brown, LLC will provide consultations in defense matters, the firm spends most of its time litigating complex litigation such as class actions, mass torts and catastrophic injuries.
Judgment with Maximum Damages for Wage & Hour Dispute
Wage & Hour dispute on behalf of hourly employees who were not paid time and a half for hours in excess of 40. Employees were granted double damages for all their time with attorney fees and costs paid separately.
Million Dollar Settlement for Wage & Hour Class Action Case
Workers were compelled to come into work 15 minutes early to set up, but were not paid for their set up time. Gap issues aside, workers received double damages for the time worked for 3 years’ worth of pay with attorney fees paid separately.
This is a non-exhaustive list of prior results and successes of Jason T. Brown and the Brown, LLC. Past results do not guarantee a similar outcome.
For more information about each award see Awards & Accolades – All cases involve Jason T. Brown and/ or Brown, LLC
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Results may vary depending on your particular facts and legal circumstances.