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Private Insurance Whistleblower Reward Programs

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Sharp HealthCare — Medicare Fraud/Kickbacks (undisclosed settlement amount)

Three of our whistleblower attorneys represented a whistleblower in a qui tam action under the False Claims Act against Sharp HealthCare, a regional hospital system in San Diego.  Our client alleged that the Sharp Healthcare Center for Research, Sharp’s clinical-trial research arm, fraudulently billed government payers in violation of “secondary payer” rules that prohibit billing the government when other payers will pay for a patient’s care. Our whistleblower client also alleged that Sharp cultivated an illegal kickback scheme to entice prospective trial sponsors to host clinical trials at Sharp by regularly undervaluing Sharp’s costs involved in managing clinical trials.  By offering below-market value incentives and billing government and commercial insurers for injuries, the lawsuit alleged that Sharp sought to increase its attractiveness to trial sponsors. Sharp’s alleged purpose was to burnish the organization’s reputation and offer a lucrative stream of income for Sharp-affiliated physicians involved in clinical trials. Sharp settled the whistleblower’s case for an undisclosed amount.  Read more here.

How to Be a Whistleblower

Posted  07/19/19
By Jessica T. Moore
How to be a whistleblower
You know about fraud, waste, abuse, or corruption by an individual or a company. Someone is getting by with cheating -- taking money from the government, taxpayers, or investors, or even harming others, such as patients. You are deeply troubled about it and want the proper authorities to stop it. You are worried whether you will be heard, taken seriously, and protected. You wonder if your information fits within a...

Healthcare Fraud also Harms Private Insurers - and Whistleblowers can Help

Posted  04/25/19
Health insurance forms, stethoscope, calculator and dollars
Whistleblowers with information about healthcare fraud look first to the False Claims Act, and the impact that healthcare fraud has on Medicare, Medicaid, and other government healthcare spending.  But, healthcare fraud that harms private insurance companies – as opposed to government payors – also attracts government enforcement attention.  Several recent criminal prosecutions in Texas and elsewhere illustrate...

March 14, 2019

The former owner and former COO of Atlanta-based Primera Medical Group, Shailesh Kothari and Timothy McMenamin, were sentenced to prison terms of 6.75 and 7.75 years, respectively, for their roles in submitting more than $8.5 million in fraudulent invoices to private insurance companies for allergy testing and allergy immunotherapy services that were never provided and were not medically necessary.  Defendants submitted bills using the NPIs of doctors who had not performed the tests and, in fact, had no knowledge of the services.  To cover up the fact that the services were not provided, defendants would create false laboratory reports for insurers and patients who requested them.  USAO ND GA

Skyline Urology — Healthcare Fraud ($2.1M)

Constantine Cannon represented a whistleblower in a qui tam lawsuit that alleged that from 2013 through 2016 a large urology practice had fraudulently and systematically misused a billing code in order to increase reimbursements from insurers, including Medicare and private insurers in California. The code, modifier 25, is properly used when a physician performs an evaluation and management service and a separate and distinct service on the same day. Billing with modifier 25 when no distinct service occurred can improperly inflate reimbursement rates and is known as “unbundling fraud.” The Federal Government recovered $1.85M and the State of California recovered $250,000 to resolve the allegations. For his efforts in uncovering the fraud, the whistleblower received a portion of both recoveries. See The National Law Review and Becker’s ASC Review for more.

Healthcare Fraud: it’s not just Medicare and Medicaid

Posted  10/17/18
Last year, the U.S. Department of Justice recovered $2.4 billion in settlements and judgments involving fraud in the healthcare industry perpetrated against government payors. But government programs like Medicare and Medicaid aren’t the only targets of massive healthcare fraud schemes. A recent Department of Justice press release announced the unsealing of a 32-count indictment containing charges against four...

January 4, 2018

Kmart Corporation agreed to a $1 million settlement with the California Department of Insurance to resolve a whistleblower claim brought under the California Insurance Fraud Prevention Act.  KMart contracted with insurance companies to be reimbursed at a rate based on the company's charges to cash-paying customers, but was alleged to have submitted claims to private insurers in amounts that exceeded the agreed-upon rates.  CA

September 5, 2017

Novo Nordisk, Inc. has agreed to $1.1 million to resolve claims that its diabetes drug Victoza was unlawfully promoted for off-label use in violation of the California Insurance Frauds Prevention Act.  The claims were brought in a whistleblower action under that act filed by former Novo Nordisk researcher Peter Dastous, who will receive a share of the settlement.  CA

Fraudster of the Week -- Monarch Medical Group

Posted  04/28/17
Last week, California state prosecutors charged 26 individuals, including 21 physicians and 2 pharmacists, in connection with a kickback scheme orchestrated by Tanya and Christopher King, the owners of a practice management company called Monarch Medical Group and other related companies.   If convicted, the involved physicians could face up to 25 years in prison and the pharmacists could face up to 28 years. ...

DOJ intervenes in $50 Million Healthcare Fraud Case

Posted  03/2/17
By the C|C Whistleblower Lawyer Team Preet Bharara, US Attorney for the Southern District of New York, announced a civil suit and criminal actions against several doctors and health care entities alleging over $50M in fraud through schemes that lasted over 12 years. Five of the six doctors charged in their personal capacity were arrested in the New York area on Wednesday. The allegations center around Asim...
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