Elder Abuse and Medicare Fraud

When it comes to financial matters, senior citizens are vulnerable to exploitation—otherwise known as elder abuse—from family members, friends, neighbors, caregivers and even businesses. More than half of elder financial fraud is committed by strangers, one-third by loved ones, and about one-tenth by businesses.

Medicare is one of the areas in which elders are at risk of becoming the victims of fraud. Unscrupulous individuals or businesses attempt to use a senior citizen’s personal and/or Medicare information to charge the Medicare program for items and/or services the elder never received.

According to the Medicare.gov website, individuals and businesses attempt to cheat Medicare in the following ways:

  • a doctor or healthcare provider bills the program for services and elder never received
  • a healthcare supplier bills Medicare for equipment an elder never ordered
  • an unauthorized person uses and elder’s Medicare card to get medical care, supplies or equipment or bills Medicare for home medical equipment after that equipment has been returned
  • a company offers a Medicare drug plan not yet approved by Medicare or willfully uses false information to mislead an elder into joining a Medicare plan

Those elders most vulnerable to financial fraud range from 80 to 89 years of age. Statistics show that these seniors usually live alone and that they are female: nearly twice the number of women as men become the victims of fraud. Perpetrators of elder financial fraud are both genders. However, the majority are men between the ages of 30 and 59 while female perpetrators are between the ages of 30 and 49.

Current estimates suggest that Americans over the age of 50 control 70% of the national wealth. Given these numbers, it’s no surprise that elder financial abuse is on the rise throughout the United States. If you suspect that you or an elderly loved one has been the victim of Medicare financial fraud, contact the attorneys at the Barrera Law Firm. We have the know-how and experience to help seniors restore their good name and peace of mind.

Health Care Fraud

If you know of health care fraud, contact us safely and confidentially to take action and make things right.

One area The Barerra Law Firm services is health care fraud. We represent the taxpayers when a person is committing fraud against the government. What is health care fraud? Health care fraud is when a health care agency, a doctors clinic, a home hospice, a nursing home, a psychiatrist, a chiropractor, anybody is making a claim to the government for compensation on behalf of another and that claim is false.

Some types of health care provider fraud have to do with unnecessary billing, unnecessary treatment, false billing or providing a basic false picture to the government for so-called services which were never rendered and false claims have been submitted.

If an individual suspects fraud within whatever area they work in, they should come to my law office and we will inform them of what their rights are concerning reporting this on behalf of the taxpayers. One of the things that they would need to have is information or evidence to show that false claims have been provided to the government on behalf of the health care industry.

They should bring that information to The Barrera Law Firm and we will evaluate that claim so that that person can then be a party to a lawsuit on behalf of the taxpayers against that health care provider that is bringing the false claims.

Medicaid Fraud Settlement Results in Millions to Texas

A recent success in combating Texas Medicaid fraud will result in $72 million being returned to the state.

The Texas Attorney General’s Office charged Par Pharmaceutical Inc., based in New Jersey, and three other drug manufacturers with defrauding the state’s Medicaid program by improperly reporting drug prices.

Because the defendants provided inaccurate market prices for their drugs, the Medicaid program over-reimbursed pharmacies for Par’s products.

Under the agreement, Par must pay $154 million to resolve enforcement actions filed by Texas and four other states.

Read the full article here.

Common Types of Medicaid and Medicare Fraud

Sadly we live in a day when some of those that are supposed to be keeping us in health instead take risks with our health for their own personal gain. While most physicians and clinics are free from Medicaid and Medicare fraud, there are many that use patients in order to gain access to these funds, and in doing so risk the health and safety not only of their own patients but also of others who depend on these funds for actual health issues. There are many ways in which Medicare and Medicaid fraud can occur, and knowing how to spot these crimes will help you from falling victim to them.

  1. Billing fraud. Billing fraud is one of the most common abuses of the Medicare/Medicaid system. There are many different scams that are perpetrated. One is billing for services that were never rendered, either by using genuine patient information, identity theft, padding real claims with false information or simply by fabricating entire claims altogether. Billing fraud is rarely committed by one person. All those who knowingly participate in billing fraud can be held liable. Reporting this type of fraud will prevent you from being found financially responsible for the theft.
  2. Falsification of patient diagnosis. Another type of Medicare/Medicaid fraud is the falsification of patient records, including tests and exams, in order to justify surgeries, treatments, procedures or drug regiments. As a patient, nurse or loved one, it is important to carefully check the information you are given to ensure that a proper diagnosis has been given. Falsification of patient records that leads to unnecessary procedures can cause serious damage and even death to these victims. Convincing patients that they have a life threatening condition that must be treated by some medical procedure is both unethical and unlawful and these physicians need to be reported for health care fraud.
  3. Unbundling of procedures. Medical procedures often require multiple steps. Typically, these steps are bundled into one cost instead of being billed separately. Unscrupulous physicians will sometimes have their accountants bill each step separately instead of in a bundle as it is supposed to be. Unbundling means that the doctor or clinic will receive much more money for the service than is deserved, and fewer funds are left over for other work.
  4. Kickback fraud. We have all heard of kickback fraud, but do you know how pervasive it actually is? Pharmaceutical companies wine and dine doctors and clinics, offering substantial kickbacks to those who push their prescription drugs. When these drugs are actually necessary for a real medical condition and result in a bettering of a condition for the patient, then no harm is done. However, all too often physicians write prescriptions for drugs which have absolutely nothing to do with the patients condition simply to take advantage of kickbacks. As well, if patients must return to the doctor month after month for a prescription refill, they profit off the charge of each office visit. Kickback fraud can be dangerous because often the drugs prescribed cause harmful side effects in patients, some even leading to death.

Dangers of Medicaid and Medicare Fraud

If you are aware of Medicaid or Medicare fraud, call The Barrera Law Firm

It is an unfortunate system we find ourselves in today, when the institutions of medicine we entrust with our health commit fraud in order to gain access to government funds. Medicaid and Medicare fraud is rampant in America, and the ramifications effect society at multiple levels. You may become aware of Medicaid or Medicare fraud being committed either as a patient or as a health care professional. Due to the inherent dangers of medicaid and Medicare fraud, it is important for it to be reported to authorities through the proper channels with the aid of a lawyer.

  1. Medicare fraud is harmful to the elderly. Medicare is supposed to be available for those of our society who are 65 and older. Often times, the elderly have health problems or complications that can stick them with medical bills that are financially unable to pay. Medicare fraud, or the funneling of Medicare funds to those who don’t really need it, means that these funds aren’t available for the elderly patients who need them to survive.
  2. Can result in the wrongful diagnosis of disease. Too often, medicare professionals diagnose an illness too quickly and prescribe medication to patients in order to get a hold of Medicare funds. For example, in Texas, unscrupulous psychiatrists often take advantage of children from low income families by convincing the family that their child has a psychological illness that must be treated by them and their prescription drugs. More often than not, the wrongful diagnosis actually prevents the real issue, if there even is one, from being discovered. These children often end up suffering permanent damage from the treatment. As a health care worker who is witness to this type of fraud, you can be held liable in a lawsuit if you do not report it.
  3. Results in wrongful healthcare statistics. Many science studies today depend on data from reports filed by physicians. When patients are misdiagnosed by deceitful physicians trying to access Medicare and Medicaid funds, the data reported to health agencies results in a skewed view of the actual health of the nation. Since these statistics are used by lawmakers and those who direct policies regarding public health, wrongful diagnosis by those knowingly committing health care fraud actually has nationwide ramifications.
  4. Drugging of the elderly in nursing homes. One of the most types of Medicare and Medicaid fraud is the drugging of the elderly in nursing homes. These are some of the most vulnerable members of our society. Nursing homes often time receive kickbacks from pharmaceutical companies for prescribing powerful anti-psychotic drugs to the elderly, whether they need them or not. Oftentimes, these drugs lead to other complications and even an early death to their users. If you are a private citizen or health care worker who is witness to this type of action taking place, you have a lawful and moral obligation to report it to the proper authorities. A law firm specializing in Medicare and Medicaid fraud can guide you on a correct course of action.

The False Claims Act and Qui Tam Lawsuit

The False Claims Act ( FCA) was originally enacted during the Civil War with the purpose of protecting the Union Army from unscrupulous suppliers. More recently, the FCA has been a powerful tool to fight fraud on the part of government defense contractors and since 1999 there have been an ever growing number of prosecutions concerning the sales, marketing and pricing practices of pharmaceutical companies.

The FCA combats fraud by imposing civil liability on individuals or entities that “knowingly presents or causes to be presented, a false or fraudulent claim for payment or approval” to the federal government. 31 U.S.C. § 3729.

Essential to the effectiveness of the FCA is the ability of whistleblowers to sue on behalf of the United States. This provision known as a “qui tam” provision allows the individual with evidence of fraud against the federal government, referred to as the “relator” to sue the perpetrator to recover the stolen funds. Qui Tam is an abbreviation of the Latin phrase “qui tam pro domino rege quam pro sic ipso in hoc parte sequitur” meaning “he who as well for the king as for himself sues in this matter.”

The FCA provides for up to treble damages, and the relator is entitled to receive between 15 and 25 percent of the amount recovered by the government through the qui tam action.

Prosecutors and whistleblowers have made headlines using the FCA to fight virtually every kind of healthcare fraud from billing for procedures that were not performed to off label marketing of pharmaceuticals. The New York Times reported on the largest FCA settlement to date in June 2012, “the British drugmaker GlaxoSmithKline agreed to plead guilty to criminal charges and pay $3 billion in fines for promoting its best-selling antidepressants for unapproved uses and failing to report safety data about a top diabetes drug. . . . The agreement also includes civil penalties for improper marketing of a half-dozen other drugs.”

However, liability extends well beyond the marketing of pharmaceuticals and into the R&D process. There is a growing trend in prosecutions associated with the falsification of data in laboratory studies and clinical trials. Should a pharmaceutical company outsource a portion of this function to a Contracted Research Organization (CRO), it is clear that pharmaceutical companies remain liable for the CRO’s actions.

Clinical and medical trial fraud occurs when a pharmaceutical manufacture provides false data to the FDA, withholds or alters negative data regarding the safety and efficacy of a drug, violates the recognized norms of research in order to influence trial outcome or fails to follow study protocol. An example of R & D fraud would be a defective pharmaceutical causing birth defects or suicidal behavior, where the manufacture concealed the risks and continued to market the drug falsely promoting the efficacy and miscoding side effects.

Clinical and medical trial fraud is actionable under the FCA as a form of healthcare billing fraud when Medicaid and Medicare (or other federally funded health program) make payments for drugs whose FDA approval was based on false information. With fraudulent FDA approval, the drug in question would not necessarily be safe or effective. And an unsafe and/or ineffective drug would not be reasonable or necessary—a requirement to be reimbursed under any federal healthcare program. Thus under the FCA, a whistleblower with knowledge of clinical trial fraud or falsification of data used in the FDA approval process, is able to bring a qui tam action against the pharmaceutical manufacturer.

Whistleblower Alert: Should Pharma Companies Pay Psychiatrists for Promotional Work in Heavy Medicaid Areas?

Federally-funded healthcare programs are being depleted at a rapid rate. Promotional work by physicians is generally allowed when not in violation of the Stark Law and the Federal False Claims Act i.e. Off Label etc. However some physicians may not be qualified as experts in the areas of medication they promote and others may have pending disciplinary matters that make them even less qualified to do promotional work in that area.

The Rio Grande Valley in Texas has over 400,000 people who are eligible to receive Medicaid. Are Pharma companies knowingly competing for that government money?

Whistleblowers are generally compensated for providing evidence of fraud on government programs such as Medicare, Medicaid and TriCare. A private attorney may assist a whistleblower to prepare a complaint on behalf of either or both the federal and state government so that funds may be recovered and the government has an opportunity to intervene. Cases are filed under seal and are highly confidential. Complex rules exist that regulate the conduct of whistleblowers.

Whistleblower Alert: Did Drug Companies Knowingly Design Certain ADD and ADHD Drugs to be Addictive?

Certain ADD and ADHD Schedule II Drugs contain combinations of amphetamine salts. Many individuals taking these develop a strong dependence on the drug, or more importantly, on the amphetamine effect that is caused by the drug. Withdrawal from these drugs may be extremely difficult.

Guidelines exist under Good Clinical Practice (GCP) as to ethical practices regarding the R&D of new drugs. Conflicts of interests and misleading statements to the government are prohibited. However, individuals having knowledge of any wrongdoing in R&D may feel intimidated to report questionable activity because of waivers and confidentiality agreements.

Whistleblowers are generally compensated for providing evidence of fraud on government programs such as Medicare, Medicaid, and TriCare. A private attorney may assist a whistleblower to prepare a complaint on behalf of either or both the federal and state government so that funds may be recovered and the government has an opportunity to intervene. Cases are filed under seal and are highly confidential. Complex rules exist that regulate the conduct of whistleblowers.

Whistleblower Alert: Is ECT Medically Necessary?

ECT machineThe government is currently paying for electro convulsive therapy (ECT) at a high cost to tax payers and at an immense profit to medical providers. Medicare, Medicaid, and TriCare often foot the bill despite questionable motivations and results. The practice of ECT is both condoned and encouraged by the American Psychiatric Association (APA), through the use of the Diagnostic Statistical Manual (DSM).

Whistleblowers are generally compensated for providing evidence of fraud relating to government programs such as Medicare, Medicaid, and TriCare. An attorney may assist a whistleblower to prepare a complaint on behalf of either or both the federal and state government so that funds may be recovered and the government has an opportunity to intervene. Cases are filed under seal and are highly confidential. Complex rules exist that regulate the conduct of whistleblowers.

Whistleblowers get terminated because they are a threat to continuing the fraud. The usual pattern is:

  1. Whistleblower gets the feeling that something is wrong in the workplace regarding schemes towards government funding and becomes concerned about participating or condoning of such action;
  2. Whistleblower points out illegal or fraudulent activity;
  3. Whistleblower becomes target to get handled or terminated;
  4. Whistleblower comes under close employment scrutiny and traps are laid; and
  5. Whistleblower gets terminated through the pretext of a carefully manipulated series of incidents.

Whistleblowers that do not come forward run the risk of facing civil and/or criminal consequences. When one experiences the feeling that something is wrong in the workplace regarding schemes towards government funded programs, smart and legal actions should be taken swiftly to avoid the inevitable consequences.

Do You Have Grounds for a Qui Tam Whistleblower Case?

The law allows a private citizen to file suit against another individual or company who is filing false bills or claims to state and/or the federal government.  The law also provides protection to those who are “demoted, suspended, threatened or harassed” for those acts done in reference to actions related to blowing the whistle on the fraud.

According to recent government audits, as much as 10% of Medicare charges are fraudulent.  Some common examples of Medicare/Medicaid fraud include:

  • billing more than once for the same service
  • kicking back money or items of value for ordering drugs or equipment
  • charging for services not performed
  • billing for expensive equipment and providing cheaper equipment instead

In 1986, the government gave the statute more teeth and made it easier for people to bring suit against offenders. Since that time, the government has recovered over $2 billion in fraudulently gotten funds and paid out approximately $340 million to whistleblowers.

Contact The Barrera Law Firm, PC at 956 428 2822 for assistance as to your rights as a whistleblower, how you put forth a claim for recovery and additional advice as to whether there are any criminal implications in your claim.