Diagnostic services provided by clinical labs and imaging companies can be a significant source of Medicare fraud. From violations of the Anti-Kickback Statute for improper compensation to medically unnecessary tests, the False Claims Act provides an enforcement mechanism for the U.S. Government to recoup some of the money lost to health care fraud.
More than half of False Claims Act cases are brought by whistleblowers. Health care professionals can earn significant rewards for providing information to the Justice Department through a qui tam lawsuit. If you have information about fraud in a diagnostic service (clinical laboratory or X-Ray / CT Scan / MRI provider), call 1-800-590-4116 for a free, confidential initial legal consultation.
Medicare spends billions annually for Part B services at clinical labs, as it is the largest payer of clinical laboratory services in the nation. Despite Medicare guidelines, laboratory fraud has been a significant problem in the health care industry.
In 2014, OIG issued a special fraud alert for compensation paid by laboratories to referring physicians and practice groups for blood collection, processing and packaging. The alert highlighted concerns about above fair market value payments to physicians for services as well as free or below-market goods / services paid by the lab for the doctor.
A 2014 OIG report also looked at questionable billing by labs for potentially unnecessary services. It found a significant number of labs exceeded its threshold for questionable billing practices, and these labs billed Medicare in total for $1 billion in lab services. Another problem identified by CMS is the ordering of a bundle of tests when only one is necessary.
In 2011, OIG identified portable x-ray providers as a small but significant source of Medicare fraud. More than half of the providers identified with questionable billing practices were in the Miami, Florida area. The questionable practices involved billing transportation for two trips to a facility in the same day as well as submissions for tests ordered by non-physicians. A separate 2016 report found that a single provider in New York billed Medicare for hundreds of thousands of dollars improperly.
MRI and CT Scans
A case against a provider of CT scans settled in 2014 for more than $10 million when, among other things, the government alleged that the company submitted claims for 3D reconstructions of CT scans that were never performed or interpreted. Allegations of fraud in the case also invoalso arises in these tests when the testing company pays the provider for referrals. An example of MRI fraud is the ordering of a MRI instead of a mammogram for preventative care.
Part B providers can not submit claims for payment when tests are not ordered by physicians or are not medically necessary.
The False Claims Act
The False Claims Act imposes substantial penalties on doctors, hospitals and other health care companies engaged in fraud while rewarding whistleblowers for providing evidence of the misconduct to the Justice Department through a qui tam lawsuit.
Our Federal False Claims Act lawyers have guided whistleblower cases to several significant settlements on behalf of relators. Our largest unsealed cases are currently focused on kickbacks in violation of the Anti-Kickback Statute, but we have a broad base of experience across other types of Medicaid and Medicare fraud. In the pursuit of suspected frauds, we have brought cases to the attention of the government in many states, including New York, Florida, California and here in Philadelphia. In 2016, for example, we helped the federal and state governments recover $54 million from a Valeant subsidiary for kickbacks paid through speaker programs.
The law rewards whistleblowers for information with between 15 and 30 percent of the proceeds from the litigation, subject to numerous terms and conditions specified in the law. During President Obama's Administration, the U.S. paid out more than $4 billion to whistleblowers. For those not familiar with whistleblower cases, we have written a quick guide to the process.
Our False Claims Act attorneys undertake a thorough review of whistleblower evidence up front during the case evaluation process. We confirm that there is sufficient evidence of both inappropriate government billings as well as evidence of intentional or reckless conduct by the individuals in charge. We understand that no one person needs to have every piece of the puzzle and we have evaluated thousands of potential cases while honing our judgment. We also answer any questions that a whistleblower has in order to ensure that you can make an informed judgment about whether to proceed with a qui tam lawsuit.
To begin the process and get your questions answered, use our contact form or call 1-800-590-4116 for a free, confidential and no-obligation initial legal consultation from our whistleblower attorneys.