Whistleblower Medicare Fraud Attorneys

Medicare provides essential healthcare services to elderly individuals. The necessary programs involve over one trillion dollars of federal funds each year nationwide. In addition to vast amounts of money, the sheer size of these programs makes monitoring very difficult. As a result, we must count on “whistleblowers” to report any fraud or abuse in Medicare or Medicaid programs.

The medicare fraud lawyers at Di Pietro Partners represent whistleblowers. We understand the courage it takes to step forward and the importance of ensuring your rights and interests are protected throughout the process. Our attorneys work on a contingency fee basis for whistleblower cases, meaning you won’t pay any legal fees unless we recover funds on your behalf. This approach aligns our success with yours and allows you to pursue justice without financial risk.

If you suspect Medicare fraud and are considering taking action, don’t navigate this challenging landscape alone. Contact our law firm for a free consultation today.

Our Medicare Fraud Lawyers on TV

What is Medicare Fraud/Abuse?

Medicare fraud or Medicare abuse refers to illegal practices aimed at exploiting the federally funded healthcare program, Medicare for financial gain. Medicare is designed to provide healthcare services to the elderly and low-income individuals and disburses over one trillion dollars annually. Given the program’s vast scale and intricate nature, effective detection and prevention of fraud are heavily dependent on the vigilance of whistleblowers.

Medicare and Medicaid fraud manifest in various forms, all sharing the common goal of illicit financial gain. Some prevalent types of fraud include:

Billing for Services Not Rendered – This involves healthcare providers submitting claims for procedures or services that patients did not actually receive. An example would be a therapist billing Medicare for comprehensive physical therapy treatments when only basic massage therapy was provided.

Upcoding – In this scenario, providers intentionally use higher billing codes for services or procedures than what was actually performed, aiming to receive higher reimbursements than they are entitled to.

Unnecessary Procedures – Billing Medicare or Medicaid for procedures that are medically unnecessary, purely to increase billing amounts, constitutes fraud. This is particularly concerning when it targets vulnerable populations, such as the elderly without family oversight.

False Documentation – This encompasses a range of deceptive practices, including billing for procedures that were never performed, patients that were never seen, or home health care visits that never occurred.

Identifying and addressing Medicare fraud is crucial for the integrity of these healthcare programs. Legal mechanisms and protections are in place to support whistleblowers in reporting such activities, ensuring that funds are used appropriately to benefit those in genuine need of medical care.

How to Report Medicare Fraud

Reporting Medicare fraud is a critical step in safeguarding the integrity of healthcare services and ensuring that resources are allocated appropriately. If you suspect fraudulent activities, the following steps are crucial:

– Gather Documentation – Collect any evidence related to the suspected fraud. This could include billing statements, emails, internal reports, or any other documents that could substantiate your claims. Ensure that you adhere to company policies and legal regulations when obtaining these documents to avoid any personal legal repercussions.

– Write a Detailed Memo – As soon as possible, document your observations and the specifics of the suspected fraud in a memo to yourself. Given that legal proceedings and investigations can extend over several years, this memo can serve as a vital record, preserving the accuracy of your recollections and observations.

– Compile a List of Relevant Documents – Make a list of any additional documents that could be pertinent to your case but are not currently in your possession. This could include internal records, billing information, or correspondence that you know exists but do not have direct access to. This list can guide investigators and legal representatives in their inquiry.

– Contact a Medicare Fraud Attorney – Reach out to a law firm specializing in Medicare fraud. These firms are well-versed in the complexities of healthcare fraud cases and can provide the necessary legal guidance and representation. They can assist in navigating the legal system, ensuring that your report is filed correctly, and that you are protected throughout the process.

– Report to Government Authorities – In addition to working with a Medicare fraud lawyer, you can report suspected Medicare fraud directly to government authorities. This can be done through the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS), or through the Medicare fraud hotline.

– Consider Whistleblower Protections – If you are reporting fraud within your organization, consider the protections afforded to whistleblowers under federal and state laws. These laws can offer protection from retaliation, ensuring that individuals who report wrongdoing are not unjustly penalized.

By following these steps, you can play a crucial role in combating Medicare fraud, contributing to a more ethical and sustainable healthcare system. Remember, effective reporting starts with accurate documentation and seeking the right legal and professional guidance.

Medicare Fraud Whistleblower Rewards

Whistleblowers play a vital role in exposing Medicare fraud. Individuals with knowledge of fraud against the government are allowed to file lawsuits on behalf of the government.

It is vital to use an experienced Medicare fraud attorney to file this type of lawsuit. An individual that chooses to file this type of lawsuit is known as qui tam relators.

With a Medicare fraud attorney’s assistance, if you win this lawsuit you are entitled to up to 30% of recovered claims. However, if the government intervenes and becomes part of the case, you may be entitled to substantial compensation.

Of course, another point to consider is how do you know this illegal activity is happening? Has your employer forced you to be involved in any way? Considering these questions, if you know that Medicare or Medicaid fraud is happening where you work, contact a Medicare fraud attorney immediately.

Recent Medicare Whistleblower Cases

Recently, numerous Medicare whistleblower cases have made the news. The lawsuits became newsworthy due to the large amounts of money involved in fraudulent schemes and the huge penalties attached to committing these crimes. Noteworthy cases include:

1. The U.S. Department of Justice Office of Public Affairs issued a press release on Tuesday, January 30, 2024. The article explained how a California man was sentenced to 10 years in prison for billing Medicare approximately $234 million for various lab tests, despite the fact he was excluded from participating in Medicare. The man was previously convicted in 1990 and 2001 in New York and California. After each conviction, he was ordered NOT to participate in Medicare or Medicaid programs. Evidently, he didn’t listen. In addition to 10 years in prison, he must forfeit $31,761,286.21, two residential properties, and one business property.
2. A Florida businessman was ordered to pay $27 million for Medicare fraud. He billed Medicare for cancer genomic testing that was not medically necessary. It’s important to note, he owned the diagnostic laboratory.
3. A Pennsylvania pharmacist submitted claims to Medicare Part D which is the prescription part of the plan. Well, the claims were then traced to non-existent orders and the drugs were never given to any patients. The pharmacist pled guilty and was sentenced to 15 months in prison and $166,000 restitution.
4. Operation Brace Yourself (2019) – Over $1.2 billion in fraudulent claims made by dozens of healthcare executives and telemedicine executives led to charges. The group billed Medicare for equipment never used or received.
5. Michigan doctor’s chemotherapy fraud (2014) – This was a horrific case. Dr. Farid Fata was convicted of administering chemotherapy to over 500 patients who didn’t have cancer. Medicare received and paid $34 million of fraudulent claims from this doctor.

How We Can Help

Our medicare fraud attorneys play a crucial role in assisting whistleblowers in bringing to light fraudulent activities within the healthcare system.

Webegin by thoroughly evaluating the details of the alleged fraud, leveraging their expertise in healthcare law to determine the viability of filing a whistleblower (qui tam) case under the False Claims Act. This preliminary assessment is vital in ensuring that the case has a solid foundation and meets the legal criteria for whistleblower actions.

Once a decision to proceed is made, our attorneys guide whistleblowers through the complex process of filing a qui tam lawsuit. This involves preparing and presenting detailed evidence of the fraud to the government, meticulously documenting the fraudulent activities, and outlining the extent of the misconduct and its impact on the Medicare program. The aim is to provide the government with a comprehensive case that can lead to successful prosecution and recovery of misappropriated funds.

Beyond filing the lawsuit, we work closely with the government throughout the prosecution phase.

Why Choose Us

Choosing Di Pietro Partners for your Medicare fraud case means securing a team uniquely equipped to navigate the complexities of healthcare law. With a robust team that includes healthcare lawyers, board certified physicians, and former government administrators, all with decades of experience, the firm brings an unparalleled depth of expertise to every case.

David Di Pietro, a seasoned healthcare and medical malpractice lawyer with over a decade of experience, has successfully represented clients through a myriad of complex healthcare issues, from misdiagnosis to medication errors. His extensive trial experience and regular appearances on national TV as an expert on significant cases, like the Purdue Pharma Opioid Lawsuit, demonstrate his commitment and aggressive approach to achieving justice for his clients.

Dr. Tiffany Di Pietro, serving as the medical advisor, adds an invaluable medical perspective to the team. As the youngest graduate from Nova Southeastern University’s College of Osteopathic Medicine and quadruple board-certified in several medical specialties, her expertise enhances the firm’s ability to scrutinize medical documents and evidence critically. Her frequent national news appearances underscore her role as a respected voice in the medical community.

By choosing Di Pietro Partners, you’re not just hiring a law firm; you’re enlisting a dedicated team of legal and medical experts committed to delivering justice and the best possible outcomes for their clients. Their comprehensive approach to handling Medicare fraud cases, combining legal prowess with medical insight, sets them apart as a premier choice for anyone seeking representation in complex healthcare litigation.

Types of Medicare Fraud

Medicare and Medicaid fraud take various forms. One common trait each fraudulent act shares is the desire to exploit the government for financial gain. In other words, the perpetrators want to make money. Some common types of Medicare or Medicaid fraud include:

• Billing for services not rendered: For example, a physical therapy practice may only provide massage therapy to patients. However, the therapist bills Medicare for ultrasound, traction, electrotherapy, ice, and heat. Each service has a code and cost involved. Thus, the therapist gets paid more for services not received by the patient. Simply put, the therapist has committed Medicare fraud.
• Coding: Providers intentionally assign a higher billing code to a service or procedure. This is illegal when the code is purposely written incorrectly to obtain higher reimbursement.
• Unnecessary procedures: Any unnecessary procedure billed to Medicare or Medicare is considered fraud. If an employee of any medical practice sees this happening, they should contact an attorney and report it. Sadly, this may happen to the elderly when no family oversees their care.
• False documentation: Billing for procedures never performed, or billing for patients not seen at the practice is illegal. Also, billing for home health care visits that never happened is fraud. Once again, employees should seek legal guidance if this is happening where they work.
• Kickbacks and Referrals: This involves receiving or offering financial incentives in exchange for the referral of patients covered by Medicare or Medicaid. It’s a violation of the Anti-Kickback Statute, aiming to ensure that medical providers’ judgments are not compromised by improper financial incentives.
• Phantom Billing: Similar to billing for services not rendered but extends to billing for more expensive services than those actually provided or billing multiple times for the same service.
• Upcoding of Patient Diagnosis: More severe than the incorrect coding of procedures, this involves exaggerating a patient’s diagnosis to justify unnecessary tests or procedures that generate higher payments from Medicare or Medicaid.
• Prescription Fraud: Involves prescribing unnecessary medications, sometimes in collusion with a pharmacy, to bill Medicare or Medicaid for medications not needed by the patient. It also includes pill mill schemes where medications, especially opioids, are prescribed without legitimate medical reasons.
• Identity Theft: Using another person’s Medicare or Medicaid information to receive healthcare services or to bill for services not rendered.
• Equipment Fraud: Billing for medical equipment, supplies, or prosthetics that were either not provided or not medically necessary. This could include durable medical equipment like wheelchairs or diabetic supplies.

Federal Medicare Fraud Laws

Federal Medicare fraud laws are designed to protect the integrity of the Medicare program by penalizing fraudulent activities that seek to deceive or misuse federal healthcare funds. These laws encompass a wide range of statutes and regulations, aimed at combating various forms of fraud and abuse within the Medicare system. Here’s an overview of some key federal laws related to Medicare fraud:

False Claims Act (FCA) – This act prohibits knowingly submitting false claims to obtain a federal payment. Under the FCA, individuals and companies can be held liable for submitting fraudulent claims to Medicare. The FCA also includes whistleblower provisions, allowing private individuals to file lawsuits on behalf of the government and share in any recovered damages.

Anti-Kickback Statute (AKS) – The AKS makes it illegal to knowingly and willfully offer, pay, solicit, or receive any remuneration to induce referrals of items or services covered by federally funded programs, including Medicare. The AKS aims to ensure that medical decisions are based on the best interests of patients rather than on inappropriate financial incentives.

Physician Self-Referral Law (Stark Law) – Specifically targeting Medicare and Medicaid fraud, the Stark Law prohibits physicians from referring patients to receive designated health services payable by Medicare or Medicaid from entities with which the physician or an immediate family member has a financial relationship, unless an exception applies.

Health Care Fraud Statute – This statute makes it a criminal offense to knowingly and willfully execute, or attempt to execute, a scheme to defraud any healthcare benefit program or to obtain, by means of false or fraudulent pretenses, representations, or promises, any money or property owned by, or under the custody or control of, any healthcare benefit program.

Violations of these laws can result in severe penalties, including fines, restitution, and imprisonment. The federal government, through various agencies such as the Department of Health and Human Services, Office of Inspector General (HHS-OIG), and the Department of Justice (DOJ) enforces these laws rigorously. These agencies work together to investigate and prosecute Medicare fraud cases, recover stolen funds, and implement measures to prevent future fraud.

Medicare Fraud Categories

Medicare fraud can be categorized based on the different parts of the Medicare program, each addressing specific healthcare services and payments. Understanding these categories can help identify and report potential fraud more accurately.

• Medicare Part A Fraud – Medicare Part A covers hospitalization and post-hospital care. Fraud in this category may involve claims for services that lack medical necessity, violations related to short, often one-day stays that do not meet requirements, or upcoding of diagnosis-related groups (DRG) to receive higher payments. Fraudulent activities aim to exploit payments intended for hospitals, skilled nursing facilities, and home health agencies.
• Medicare Part B Fraud – Medicare Part B pays for outpatient medical services, including physician services, laboratory services, and diagnostic tests. Fraud here might include billing for unrendered services or items, laboratory unbundling or upcoding, and billing for medically unnecessary services. The manipulation of billing codes and the falsification of records to meet payment conditions are common tactics.
• Medicare Part C Fraud – Medicare Part C, or Medicare Advantage, allows enrollees to receive benefits through private health organizations. Fraudulent practices may involve cost-containment strategies that compromise patient care, failure to pay providers, or failure to provide necessary services. Upcoding diagnoses to inflate payments from CMS based on beneficiaries’ risk-adjusted scores is a notable form of fraud in Part C.
• Medicare Part D Fraud – Medicare Part D provides prescription drug coverage. Violations in this part may include billing for drugs not dispensed, off-label marketing, submitting claims for non-covered drugs, and engaging in unlawful kickbacks. Fraud may also involve submitting claims for brand-name drugs when generics are dispensed.

Each of these categories represents a unique aspect of Medicare, with fraudsters exploiting specific vulnerabilities to illicitly gain financial benefits. Reporting such activities is crucial in protecting the integrity of Medicare and ensuring that funds are used appropriately to benefit eligible recipients. If you suspect Medicare fraud, gathering documentation and contacting specialized Medicare Fraud Attorneys can be an essential step in bringing these activities to light and holding perpetrators accountable.

Other Types of Healthcare Fraud

Besides Medicare fraud, the healthcare industry faces various other types of fraud that can significantly impact both the financial integrity of healthcare systems and patient care. These include:

Medicaid Fraud – Similar to Medicare fraud, Medicaid fraud involves illegal practices aimed at exploiting the Medicaid program, which provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Fraudulent activities can include billing for services not rendered, upcoding, and billing for medically unnecessary services.

Private Insurance Fraud – This type of fraud involves submitting false or exaggerated claims to private health insurance companies. Tactics include billing for services not provided, double-billing both the insurance and the patient, and performing unnecessary procedures to increase billing.

Prescription Drug Fraud – Prescription drug fraud can involve various schemes, including “doctor shopping” to obtain multiple prescriptions, forging or altering prescriptions, and illegal distribution and sale of prescription medications. Pharmaceutical companies may also engage in fraud through off-label marketing or manipulating prices.

Kickbacks and Referral Schemes – Illegal kickbacks involve receiving or paying something of value in exchange for referrals for services that will be billed to a healthcare program. The Anti-Kickback Statute specifically targets this type of fraud to ensure medical decisions are based on patient needs rather than financial incentives.

Provider Identity Theft – Fraudsters may use a healthcare provider’s identity to submit false claims for services never rendered or to obtain controlled substances for illegal distribution. This not only defrauds healthcare programs but also damages the reputation of the providers whose identities are stolen.

Upcoding and Unbundling – Upcoding involves billing for a more expensive service than was actually provided, while unbundling refers to billing each step of a procedure as if it were a separate procedure to increase the total bill. Both practices are illegal and inflate healthcare costs fraudulently.

False or Exaggerated Claims for Disability Benefits – Submitting false or exaggerated claims to obtain disability benefits from government or private insurers constitutes fraud. This can include misrepresenting one’s health condition, employment status, or income.

Addressing these types of healthcare fraud requires vigilant monitoring, strict enforcement of laws, and public awareness. Healthcare fraud not only drains resources but also compromises patient care and increases costs for everyone in the healthcare system.

Medicare Fraud FAQ

Q. What happens when you report Medicare fraud?
Once you report Medicare fraud, the relevant agency (OIG or CMS) will review your report to determine if there is enough information to warrant an investigation. If an investigation is initiated, it will be conducted confidentially. You may or may not be contacted for further information, depending on the specifics of the case. Investigations can lead to various outcomes, including recovery of stolen funds, penalties for the fraudsters, and in some cases, criminal prosecution.

Q. Where do you report Medicare fraud?
Medicare fraud can be reported to: The Office of Inspector General (OIG), The Centers for Medicare & Medicaid Services (CMS), The Senior Medicare Patrol (SMP), which can also assist with fraud reporting and provides resources for Medicare beneficiaries. When considering reporting Medicare fraud, engaging a specialized Medicare fraud law firm can significantly enhance the process beyond simply submitting a report to regulatory bodies. Medicare fraud attorneys bring a wealth of expertise in healthcare law, ensuring that reports are not only accurately filed but also meticulously documented and presented in a manner that underscores the seriousness of the allegations.

Q. How do you report Medicare fraud anonymously?
If you wish to report Medicare fraud anonymously, it’s advised that you do so through a reputable law firm. When you do it this way, your legal rights are protected through attorney-client privilege. While providing your contact information can be helpful for the investigation, it is not mandatory, and your report can still be submitted and processed anonymously.

Q. What are the penalties for Medicare fraud?
The penalties for Medicare fraud may be quite severe. Civil or criminal charges are filed depending on the severity of fraud. Healthcare providers found guilty of Medicare or Medicaid fraud may face substantial fines or imprisonment. Also, the provider may be excluded from participating in any government healthcare program in the future. Finally, the guilty party may face civil lawsuits brought by the government or whistleblowers seeking damages.

Q. What is the cost of a Medicare fraud lawyer?
The cost of hiring a Medicare fraud lawyer can vary widely based on several factors, including the complexity of the case, the lawyer’s experience, and the law firm’s billing practices. The Medicare fraud attorneys at Di Pietro Partners work on a contingency fee basis on whistleblower (qui tam) cases under the False Claims Act. This means the lawyer only gets paid if you win the case or reach a settlement, taking a percentage of the recovered funds as their fee. This percentage can vary but typically ranges from 20% to 40% of the recovery.

Talk to a Medicare Fraud Attorney

Given the complexities and potential consequences of reporting Medicare fraud, consulting with a specialized Medicare fraud attorney is a crucial step. Whether you’re a healthcare professional who’s noticed questionable billing practices or a concerned citizen aware of fraudulent activities, your actions can play a pivotal role in safeguarding the integrity of Medicare and protecting vital resources.

At Di Pietro Partners, our team of experienced Medicare fraud attorneys, bolstered by healthcare professionals and former government administrators, is uniquely equipped to navigate the intricacies of Medicare fraud cases. With our extensive background in healthcare law and a proven track record of handling complex legal challenges, we’re committed to providing the highest level of representation and support.

We understand the courage it takes to step forward and the importance of ensuring your rights and interests are protected throughout the process. That’s why we offer a confidential, no-obligation consultation to discuss your case and explore your legal options. Our attorneys work on a contingency fee basis for whistleblower cases, meaning you won’t pay any legal fees unless we recover funds on your behalf. This approach aligns our success with yours and allows you to pursue justice without financial risk.

If you suspect Medicare fraud and are considering taking action, don’t navigate this challenging landscape alone. Contact Di Pietro Partners today to schedule your free consultation. Together, we can work to hold fraudulent parties accountable, recover stolen funds, and ensure Medicare remains a sustainable resource for those who depend on it.