Healthcare & Medicare Fraud
The False Claims Act (“FCA”), enacted in 1863, is the primary tool used to combat all Government fraud. Healthcare fraud, specifically Medicare and Medicaid fraud, accounts for the vast majority of all FCA claims. Civil recoveries for healthcare fraud accounted for approximately 83% of all FCA recoveries—approximately $2.6 billion in 2019, $1.8 billion in 2020, and $5 billion in 2021.
Reese Marketos’s qui tam practice features two former Assistant United States Attorneys, Josh Russ and Andrew Wirmani, with extensive experience investigating and prosecuting health fraud. During his time with the government, Josh Russ pursued healthcare cases involving Anti-Kickback Statute and Stark Law violations as well as opioid abuses. For his part, Andrew Wirmani prosecuted some of the largest healthcare fraud cases in Texas history, including the Forest Park Medical Center case and dozens of cases in the laboratory space.
Who commits healthcare fraud?
- Managed care organizations
- Laboratories and diagnostic testing facilities and providers
- Skilled nursing facilities
- Medical device and durable medical equipment (DME) manufacturers and distributors
- Home health and hospice providers
Medicare and Medicaid fraud means:
- Knowingly submitting, or causing to be submitted, false claims or making misrepresentations of fact to obtain a federal healthcare payment for which no entitlement would otherwise exist;
- Knowingly soliciting, receiving, offering, or paying money or property (e.g., kickbacks, bribes, or rebates) to induce or reward referrals for items or services reimbursed by federal healthcare programs; and
- Making prohibited referrals for certain healthcare services.
- Knowingly billing for services at a level of complexity higher than services actually provided or documented in the medical records (including upcoding or unbundling codes);
- Knowingly billing for services not furnished, supplies not provided, or both, including falsifying records to show delivery of such items;
- Billing for services and items that are not medically necessary;
- Paying for referrals of federal healthcare beneficiaries;
- Billing for services that were not provided; and
- Billing for appointments patients fail to keep.
Financial awards to whistleblowers for reporting healthcare fraud can be significant. Whistleblowers may be entitled to receive between 15 percent to 25 percent of what the government recovers.