Whistleblower Lawyers: For-Profit Nursing Home Employees May Have Whistleblower Claims

MIAMI, FL, May 06, 2013

Out of the many billions of dollars that the federal government pays to reimburse healthcare providers under the Medicare program, enormous amounts of money end up lining the pockets of fraudsters. Although Medicare fraud occurs throughout all sectors of the healthcare industry, a recent study found that for-profit nursing homes account for more than their fair share of fraudulent payments.

For-profit nursing homes "earn" close to $1.5 billion every year through a fraudulent practice known as over-billing. Over-billing occurs when a healthcare provider bills Medicare for more than the statutory amount for the medical equipment or services it provided.

Healthcare employees and other individuals are entitled to bring lawsuits under the False Claim Act on behalf of the federal government to bring this kind of fraud to light. In return, these "whistleblower" plaintiffs receive a portion of the government's recovered damages.

Individuals who have first-hand knowledge of over-billing should seek legal advice about their options. These cases are often very complicated. An experienced whistleblower lawyer can help determine whether a claim exists.

Medicare Over-Billing Comes In Many Forms

Medicare's reimbursement model creates numerous opportunities for fraud. Healthcare providers, including nursing homes, hospitals, clinics, physicians and medical equipment suppliers, provide services and goods to Medicare enrollees and then submit a bill to the government. Because of the massive volume of these claims, the government generally follows a "pay first, ask questions later" approach.

This means that thousands of businesses and individuals around the nation have tried to fraudulently overcharge Medicare in various ways. Some of the most common forms of fraudulent billing include:

- Billing for services that the facility never actually provided
- Billing for services which are not medically necessary
- Charging more than the approved reimbursement amount
- Submitting higher-paying codes on the claim form (a practice known as "up-coding)
- Submitting claims on a piecemeal basis instead of as a package as required by Medicare rules (a practice known as "unbundling)

For-Profit Nursing Homes Attract Renewed Attention for Over-Billing

According to new statistics, for-profit nursing homes over-bill Medicare on a regular basis. One news organization is reporting that for-profit nursing homes might submit improper claims thirty percent of the time - dramatically more than non-profit facilities that submit improper charges in an estimated 12 percent of claims.

Healthcare inspectors released a report in November, 2012 concluding that the government pays $1.5 billion as a result of over-billing by for-profit nursing homes. This accounts for 5 percent of all Medicare payments to nursing homes. These businesses obviously have more of an incentive to seek reimbursements from as many sources as possible - including illegal billing practices.

Because of the rapid growth of for-profit nursing homes and other healthcare facilities, observers expect that this source of Medicare fraud will only increase in coming years. Government prosecutors pursued 120 cases against nursing homes between 2008 and 2012. In the previous five-year period, the government only brought half that many cases. Compared with the overall growth of all cases by only 60 percent, the 100 percent increase in nursing home investigations highlights the scope of the problem of nursing home over-billing.

Medicare fraud is already a top priority for federal investigators - but the government has only limited resources to seek out specific evidence of over-billing. As a result, these cases often rely on private whistleblowers to report Medicare fraud.

The Basics of Whistleblower Claims

Under the False Claims Act, individuals are empowered to bring a lawsuit as whistleblowers on behalf of the government under some circumstances. These whistleblower lawsuits (also known as "qui tam" claims) allow the government to recover some of the money that it paid on a false or fraudulent bill.

When a "qui tam" claim is successful, the whistleblower is entitled to part of the recovery. This functions as an incentive to encourage plaintiffs to uncover fraud. Between 1987 and 2008, whistleblower claims recovered $22 billion on behalf of the government - private plaintiffs kept as much as 20 percent of this amount.

Several requirements apply to potential whistleblowers. One of the most important requirements involves timing: the plaintiff must be the first person to draw government attention to a specific case of fraudulent billing. As a result, it is important for potential plaintiffs to consult with an experienced whistleblower lawyer as soon as possible to avoid losing a possible claim.

Litigation Partners, P.L. and The Whistleblower Law Firm is a team of federal whistleblower protection attorneys working together to protect the rights of consumers and whistleblowers throughout the United States. From offices in Miami, Florida, our team of experienced trial attorneys represents individuals who have been harmed by defective or dangerous products or who are willing to take a stand against fraud and waste committed at the expense of U.S. taxpayers.

Additional Resources:
Whistleblower Protection Blog: http://www.federalwhistleblowerlawyers.com/blog/
How to Report Medicaid Fraud: http://www.federalwhistleblowerlawyers.com/Types-of-Employer-Fraud-Wr ... raud.shtml
How To Report Fraud: http://www.federalwhistleblowerlawyers.com/State-Federal-Whistleblower-Laws/
How to Report Tax Fraud: http://www.federalwhistleblowerlawyers.com/Types-of-Employer-Fraud-Wr ... raud.shtml
How to Report Business Fraud: http://www.federalwhistleblowerlawyers.com/Types-of-Employer-Fraud-Wrongdoing/
How to Report Insurance Fraud: http://www.federalwhistleblowerlawyers.com/Types-of-Employer-Fraud-Wr ... raud.shtml