Whistleblowers are playing a key role in revealing Medicare kickback schemes disguised as so-called patient assistance programs. In April, five separate pharmaceutical companies paid a total of $247 million for running such programs. This week, a new qui tam suit was unsealed.

Kaiser Health News offers a round up on the case:

The American Kidney Fund is supposed to help patients pay for health insurance premiums and other costs for treatment based solely on a patient’s financial need, and not favor companies that donate to it. But a new whistleblower lawsuit claims the charity created a so-called blocked list of dialysis clinics whose patients would not get financial assistance while it made sure patients at clinics operated by DaVita and Fresenius would.

The story notes that the Department of Justice declined to join the case. The lawsuit makes many of the same claims outlined in a 2016 New York Times series. Here’s what the Times reports on the new developments:

The lawsuit, filed by David Gonzalez, who worked for 12 years at the kidney fund in its patient assistance program until he left in 2015, accused the charity of creating a so-called blocked list of dialysis clinics whose patients would not get financial assistance while making sure patients at clinics operated by DaVita and Fresenius would…
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Medicare and Medicaid are the deep pockets of the federal budget, paying out nearly $1 trillion in 2018. So, it’s no wonder the programs are targets for fraudsters. Some steal from the sick. Some steal money meant to soothe the dying.

So, a new Department of Health and Human Services report on poor quality hospice care is a reminder: Whistleblowers, who have helped expose hospice billing fraud under the False Claims Act, may also have a role in ensuring quality care. It is essential to protect the False Claims Act to target cases of Medicaid or Medicare fraud.

Increasingly, billing for substandard care is considered a form of fraud, attorney Nina Zhang wrote on the American Bar Association website in March.

The False Claims Act (FCA) has emerged, for better or for worse, as a quality enforcement tool. With quality of care as an ever-moving target by the federal government (with the constant development of new quality measures), the FCA has faced its share of criticism as too blunt of an instrument to regulate quality of healthcare, a matter that many argue is better left to the states under their police power…However, it can be argued that since the federal government is the biggest buyer of healthcare, it thus has a stake in how its monies are used.”

Whistleblower hospice cases generally involve care that was not needed or never delivered. In June, a Los Angeles doctor was charged in a $33 million fraud scheme that involved hospice care. Last year, a nurse blew the whistle on a for-profit hospital chain. Caris Healthcare agreed to repay $8 million for submitting hospice bills for patients who were ineligible for the because they were not terminally ill. Sometimes billing and quality of care are intertwined. In a 2018 Texas case, a doctor told an informant that the way you make money on hospice patients “is by keeping them alive as long as possible.”


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Two whistleblower cases unsealed this week reveal how aggressive pharmaceutical marketing programs can cross the line into Medicare fraud and kickbacks. Trips to the Kentucky Derby for doctors and huge bonuses for sales reps can lead to bribes, conflicts of interest and poor-quality care.

Illustration: Tinker ReadyIn one case, a drug maker was competing with a far less expensive, easier-to-administer alternative. Sales reps reportedly told doctors they could shorten a two-to-three week treatment with the Questcor’s expensive anti-seizure drug to one week. However, the Food and Drug Administration had not vetterd the efficacy of the one-week course, according to the case.

US WorldMeds

In the settlement case, the company is charged with secretly covering co-pays for all Medicare patients –not just those in need — thus insulating them from a steep price hike. Good for the patients, whose co-pays could have reached $5,000, DOJ noted; bad for the rest of us, who have to pay the balance. That’s why the approach is considered a kickback.


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medical-stethoscope-blue-pen-paper-medicare-fraudIn a recent interview with the AARP, Attorney General Sessions took a strong stance against Medicare fraud and empowering Medicare whistleblowers. Sessions stated that it’s time to consider taking Medicare fraud as seriously as the war on drugs (certainly an issue Attorney General Sessions believes to be of paramount importance).

Medicare fraud is a serious issue. It is estimated that 10% of Medicare funds are lost to fraud and waste, totaling approximately $16.2 billion. This suggests that billions of dollars, which should be directed to funding health care for our seniors, are instead going to fraudsters taking advantage of American taxpayers and the elderly.


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The Department of Justice recently announced the settlements, listed below, in False Claims Act cases. The False Claims Act permits private parties to sue on behalf of the government those who falsely claim federal funds or avoid paying funds owed to the government.  The United States may intervene in and take over the lawsuit.  The False Claims Act also allows the whistleblower to receive a share of any funds recovered through the lawsuit. The False Claims Act is one of the most powerful tools to combat government contract fraud. 
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The Department of Justice announced today that Medical device manufacturer ev3 Inc., formerly known as Fox Hollow Technologies Inc., has agreed to pay the United States $1.25 million to resolve allegations under the False Claims Act that Fox Hollow caused certain hospitals to submit false claims to Medicare for unnecessary inpatient admissions related to minimally-invasive atherectomy procedures. 
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Yesterday, the Justice Department announced that Community Health Systems, Inc., the nation’s largest operator of acute care hospitals, has agreed to pay $98.15 to settle multiple lawsuits against it filed under the False Claims Act. Nine whistleblowers stepped forward to report “a deliberate corporate-driven scheme” to bilk the U.S. taxpayers of millions of dollars.

This