The False Claims Act was specifically structured during the Civil War era to eliminate the infiltration of fraud and scams upon American taxpayers by way of government contracts. The Act was originally initiated in response to attempts by fraudulent companies found to be double-billing or overselling war-related goods to soldiers during the Civil War. From there, it has expanded to address a range of issues, including healthcare fraud.
Presently, the federal government has recovered billions of dollars under the FCA for misconduct arising between healthcare facilities and healthcare entities like Medicare, Medicaid and Tricare. Specifically, facilities are routinely facing allegations of submitting fraudulent invoices and over-billing patients for routine care.
In the latest government settlement, Baptist Health Systems has remitted $3.7 million dollars back to American taxpayers following allegations of unlawful billing practices against Medicare. Specifically, Baptist failed to inform Medicare that certain patients were eligible for coverage under an alternative health insurance policy and continued to bill the government for services that could have been reimbursed under these private policies.
Details of the Case Against Baptist Healthcare
The investigation against Baptist Healthcare began in 2003 and lasted until 2007 after whistleblower Norma Riviera commenced her claim in the U.S. District Court in San Antonio, Texas. In details provided by the Department of Justice, a former insurance auditor for the Texas-based hospital system reported the misconduct under the qui tam provisions of the FCA, which award whistleblowers up to 30 percent of any amount recovered by the government. Texas-based Baptist Health Care recently settled with the government for over $13 million. Allegations stemmed from its alleged unlawful double-billing practices against Medicare.
Medicare is a government-backed health insurance program that is designed to be a supplemental program if a policyholder has an additional, or primary, insurance provider. In that event, the policyholder must use his private insurance plan and thereafter submit a claim to Medicare for the difference.
Between 2003 and 2007, Baptist Healthcare was found to have been submitted claims directly to Medicare without regard to whether a particular patient had a primary private plan to pick up some of costs. In addition, Baptist is alleged to have submitted claims to both Medicare and a private provider, thereby double-billing for the same service and pocketing the extra amount received.
Department of Justice Commends Baptist for its Cooperation
The DOJ was very clear in its statements that the allegations against Baptist were not related in any way to its patient services or quality of care. In addition, DOJ attorney Harold Brown commended Baptist for its cooperation and willingness to initialize internal audits.
The whistleblower in this case, Ms. Rivera, is set to receive approximately $500,000 for her role in this case.
Not Every Fraud is Replete With Evil, but all Must be Eliminated
We have certainly reported on far more heinous and complex acts of fraud against the government. In one post, we described a Medicare billing scheme wherein an oncologist was fraudulently diagnosing patients with cancer in order to collect reimbursements. In another post, we detailed a scheme wherein a pharmaceuticals company was illegally marketing certain drugs to subdue dementia patients despite the absence of FDA approval. To date, the FCA has recovered billions of dollars for American taxpayers. Many experts credit the FCA’s incentivizing whistleblower provisions for its success.
While the facts of this case do not necessarily arise to the deplorable nature of the above-mentioned cases, Baptist was still found to be bilking U.S. taxpayers out of money and contributing to rising healthcare costs for us all. If you are aware of suspicious acts at your place of employment and believe misconduct may be afoot, contact a whistleblower attorney right away.