Medicare Fraud Lawyers Tell Us Your Story

Medicare Fraud Lawyers

If you are the victim of Medicare fraud, do not hesitate to contact the conspiracy and fraud attorneys of Wallace Miller to discuss your case. We could represent you in a class-action suit or qui tam lawsuit against the fraudulent party. You might be entitled to compensation for your losses, such as healthcare costs and billing fees.

Medicare fraud typically involves a violation of the False Claims Act. Hospitals, pharmacies, and other providers violate federal and state regulations, harming patients and consumers. Some people suffer significant financial losses due to illegal billing, misrepresentation, and other deceptive conduct. As a consumer, you have a right to pursue legal action against the individual or company.

Wallace Miller understands the uphill battle you face. Fighting against entities such as physician groups, HMOs, and hospitals is a challenge. These parties often do whatever it takes to avoid accepting liability, so they don’t have to compensate their victims. Unfortunately, it’s a fight you cannot and should not attempt alone. You will likely walk away without the monetary award you deserve if you file your lawsuit without seeking legal representation.

Our Medicare fraud lawyers are ready to represent you in your case and hold the fraudulent company accountable for its wrongdoing. We will review the circumstances of your case and create an effective strategy to try to resolve it favorably. Our team will be the advocate you need to protect your rights and navigate the complex legal process. You can depend on us to fight by your side for the justice and compensation you deserve.

Call Wallace Miller at (312) 261-6193 for your free consultation and learn more about the available options.

How the False Claims Act Protects the Public

The False Claims Act (FCA) is a federal law prohibiting organizations and individuals from making false records or filing false claims involving federal healthcare programs funded by the United States government or a state healthcare system.

The FCA pursues legal action against fraudulent companies independently. However, it also allows private citizens to file lawsuits on the government’s behalf. This type of case is called a qui tam suit. The successful recovery of a monetary award allows these individuals to recover a portion of the government’s proceeds.

Whistleblower protections are available under federal regulations. Any employee who reports a violation of the FCA against an employer should not face discrimination, termination of employment, harassment, or other types of retaliatory actions. Reporting an employer’s illegal acts allows the individual to pursue recovery of financial compensation.

Violations of the False Claims Act

Medicare fraud and abuse typically involve a False Claims Act violation. Medical providers, such as hospitals, home health agencies, HMOs, physician groups, pharmacies, and skilled nursing facilities, are often organizations that violate federal and state laws.

The most common FCA violations include:

  • Hospice fraud
  • Medicare Advantage risk adjustment fraud
  • Duplicate billing
  • Billing for undelivered products or services never rendered
  • APC fraud
  • Kickbacks for illegal patient referrals
  • Upcoding
  • Medicare-funded managed care fraud
  • Part A Admissions lacking medical necessity, including observation and inpatient services
  • RUG upcoding
  • Pharmaceutical fraud
  • Falsifying patient records
  • Misrepresenting products or services
  • Billing for supplies or services never ordered
  • Diagnosis-related group fraud
  • Case-mix creep
  • Billing for procedures over multiple days despite the treatment occurring in only one visit
  • Medical loss ratio fraud
  • Falsified medical tests and results by clinical laboratories
  • Billing for medically unnecessary services

If you believe your provider violated the FCA, you should reach out to Wallace Miller immediately. One of our experienced and skilled Medicare fraud lawyers can investigate and determine whether we can hold them liable for the harm you suffered.

Common Types of Medicare Fraud

Medicare is an insurance program funded by the government. It provides coverage to people at least 65 years old or those who have an illness or disability. Fraudulent activity involving Medicare occurs when healthcare professionals and facilities engage in illegal or deceptive practices.

An individual or entity could defraud or attempt to defraud any one of the four parts of the Medicare program. The most common violations of each part are below.

Medicare Part A Fraud

Medicare Part A authorizes hospitalization and post-hospitalization care payments with federal funds. Typically, this includes paying home health agencies, hospitals, and other facilities under the Prospective Payment System (PPS).

The most common types of Part A violations include:

  • One-day stay violations
  • Upcoding of diagnosis-related groups
  • Lack of medical necessity

Medicare Part B Fraud

Medicare Part B authorizes federal funds to pay for medical and other health services, including laboratory, physician, outpatient therapy, radiology, and diagnostic. Medicare provides payment to the patient or the hospital, doctor, or another entity or supplier for covered services.

The most common violations under Medicare Part B include:

  • Increasing units of service subject to a payment rate
  • Upcoding or unbundling of laboratory services
  • Billing for services that are not medically necessary
  • Misrepresenting products or services
  • Billing for products not ordered or services not rendered
  • Falsifying records to meet the conditions of participation or payment

Medicare Part C Fraud

Medicare Part C, also called Medicare Advantage, allows beneficiaries to recover medical benefits through a privately managed healthcare organization (MA organization). Common Part C violations include:

  • Upcoding diagnoses in the Centers for Medicare & Medicaid Services Managed Care Organization risk adjustment processing system or encounter data system
  • Cost-containment at the expense of a patient’s care that drives the relationship between physicians and MA organizations
  • Inflated administrative and general costs
  • Intentionally failing to pay providers or provide reasonable and necessary services to beneficiaries

Medicare Part D Fraud

Beneficiaries of Medicare Part D have access to coverage through Medicare Advantage for prescription drugs and stand-alone prescription drug plans. Common types of Part D violations include:

  • Pharmaceutical manufacturers engaging in off-label marketing
  • Providing physicians with unlawful kickbacks or submitting false information associated with obligations under the Discount Program Agreement
  • Submitting a claim or false documentation for the same prescription to more than one payor
  • Submitting claims or false documents for brand name prescriptions despite dispensing the generic version
  • Submitting claims or false documentation for drugs not covered under Part D
  • Submitting claims or false documents for medications never provided

It’s vital to report violations of specific Medicare plans promptly. You can contact Wallace Miller, so we can file a claim on your behalf.

How to Pursue a Class Action Lawsuit

When an individual or organization harms a large group, those people can join together in a class-action lawsuit. Class actions allow multiple plaintiffs to consolidate their cases into a single legal action. All must have suffered the same or similar harm by the same defendant.

Medicare fraud can involve a significant number of patients nationwide. One or several individuals can be the named representatives in the lawsuit. The representatives must represent the interests of every plaintiff involved in the case.

A successful class action often leads to a financial award that will be split equally among the class.

Compensation Available for Medicare Fraud

If you suffered losses due to an organization’s fraudulent actions involving Medicare, you could pursue a case against them. The compensation you receive if you choose to pursue an individual lawsuit might cover various losses you’ve endured, including:

  • Financial losses and incurred interest resulting from the fraud
  • Reasonable attorneys’ fees
  • Court costs
  • Additional expenses due to the fraudulent activity

Punitive damages might also be available in a lawsuit. State laws vary, but this form of compensation is only recoverable if there’s clear and convincing evidence of the defendant’s misconduct. Some states require showing proof of particularly egregious or negligent acts. Others require evidence of the defendant’s disregard for the health and safety of others.

Wallace Miller can investigate and determine the type of compensation you are entitled to in your lawsuit. We know how to maximize the value of any case to cover our client’s total losses. We will aggressively pursue the money owed to you, so you’re not left with out-of-pocket expenses.

Pursuing a Lawsuit Under the False Claims Act

A whistleblower is a person who reports on a company’s or individual’s illegal activity. If you work in a healthcare setting and know that someone has committed Medicare fraud, you can report them under the False Claims Act.

You must have inside or non-public knowledge of federal or state regulations violations. The law protects you against retaliation by your employer for reporting what happened.

Once you file your complaint, the government will investigate and decide whether it wants to pursue legal action. You can continue participating in the lawsuit, but the government will take the lead in the proceedings. You can pursue an individual lawsuit if they decide they don’t want to bring a case against the fraudulent company. However, the government could change its mind about its involvement at any time and intervene.

The U.S. Securities and Exchange Commission (SEC) authorizes the compensation provided to whistleblowers. The monetary award depends on the extent of participation and cooperation in the lawsuit and the defendant’s prosecution. Whistleblowers can recover a percentage of the proceeds the government receives. However, a higher percentage is available if the government doesn’t pursue a lawsuit and you seek legal action yourself.

Contact Us

If you suffered losses due to a healthcare provider or organization’s Medicare fraud or if you know of Medicare fraud and want to pursue a whistleblower action, contact Wallace Miller right now. One of our Medicare fraud lawyers can meet you for a free consultation to discuss the fraudulent behavior and determine whether we can proceed with a case against the wrongdoer. Call us at (312) 261-6193 or reach out to us online.

Tell Us Your Story