Criminal Defense Lawyers

How the False Claims Act Helps Fight Medicare Part D Fraud

Introduction

Medicare Part D is a program that helps seniors and disabled people get prescription drug coverage. It’s part of the Medicare program run by the Centers for Medicare and Medicaid Services (CMS). Unfortunately, Medicare Part D is vulnerable to fraud just like other government healthcare programs.

The False Claims Act is an important tool for fighting fraud against Medicare Part D. It allows whistleblowers to file lawsuits on behalf of the government against companies that commit fraud. Qui tam provisions in the False Claims Act let whistleblowers get a portion of money recovered from fraudsters. This encourages insiders to report misconduct.

Types of Medicare Part D Fraud

There are lots of ways dishonest pharmacies, drug companies, and healthcare providers try to cheat Medicare Part D. Here are some common schemes:

• Billing for drugs that were never dispensed
• Billing for brand name drugs but giving patients generic versions instead
• Billing for refills that patients didn’t request
• Using stolen patient information to bill Medicare for fake prescriptions
• Getting kickbacks for prescribing certain medications
• Inflating costs for prescription drugs

CMS predicted Part D would be a target for fraudsters when the program launched in 2006. Sadly, they were right. Losses from Part D fraud are estimated at over $4 billion per year.

How Qui Tam Lawsuits Work

The False Claims Act lets whistleblowers file qui tam lawsuits alleging fraud against the government. Here’s how it works:

1. A whistleblower with inside knowledge of the fraud files a lawsuit under seal.
2. The Department of Justice investigates the allegations while the case remains under seal.
3. DOJ can choose to intervene in the lawsuit and take over the case.
4. If DOJ intervenes, the whistleblower gets 15-25% of recovered funds.
5. If DOJ declines, the whistleblower can pursue the case on their own and get 25-30% of recoveries.

Over 80% of False Claims Act recoveries come from healthcare fraud like Medicare Part D scams. Whistleblowers are crucial for uncovering and prosecuting these crimes.

Recent Medicare Part D Fraud Cases

Here are a few recent False Claims Act cases involving Medicare Part D fraud:

• UnitedHealth Group – UnitedHealth paid $400 million to settle allegations they overcharged Medicare by submitting inaccurate data about patient health.
• WellCare – This Florida health insurer paid $200 million to resolve claims they inflated patient risk scores to overcharge Medicare.
• Freedom Health – Freedom Health agreed to pay $31.5 million to settle allegations of fraudulently diagnosing patients to get higher payments.

These settlements show how whistleblowers and the False Claims Act are vital for protecting taxpayers from Medicare Part D fraud.

Penalties for Committing Medicare Part D Fraud

Those who defraud Medicare Part D face stiff penalties under the False Claims Act. These can include:

• Treble damages – Defendants must pay back 3 times what they stole from the government.
• Civil penalties – Fines of $11,803 to $23,607 per false claim.
• Exclusion – Providers can be banned from participating in federal healthcare programs.
• Criminal prosecution – Medicare fraud can lead to 5-10 years in prison.

With so much to lose, the False Claims Act helps deter fraud against Medicare Part D.

How to Report Suspected Medicare Part D Fraud

If you suspect Medicare Part D fraud, here are some ways to report it:

• File a qui tam lawsuit under the False Claims Act
• Report it to the Department of Health and Human Services Office of Inspector General hotline at 1-800-HHS-TIPS
• Contact CMS directly about potential fraud
• Report it to your Medicare drug plan’s compliance department

Medicare Part D fraud harms taxpayers, patients, and the integrity of federal healthcare programs. The False Claims Act is an important tool for whistleblowers to hold fraudsters accountable. With your help, we can protect this vital program for seniors and disabled Americans.

References

[1] Cigna Group to Pay $172 Million to Resolve False Claims Act Allegations

2
Medicare Part D Fraud – False Claim Act Law Firm

3
Medicare Fraud & Abuse: Prevent, Detect, Report

4
Primary Care Physicians to Pay $1.5 Million to Resolve False Claims Act Liability

5
Medicare Part D Sponsor Fraud and the False Claims Act