Healthcare Whistleblowing Versus Medicare And Medicaid Whistleblowing - EXPLAINED

Many state and federal laws prohibit companies from retaliating against their employees who have come forward and reported certain practices within the organizations that are possibly threatening public health and safety, or violating the law. There are certain other laws as well, prohibiting retaliation against employees who have filed complaints against their own working conditions, including unprotected working conditions. The laws, although, differ from state to state, the anti-retaliation laws typically forbid adverse actions, for example, layoff, termination, suspension, demotion, reduction in pay, discipline, and denial of benefits, when the unfavorable actions are the results of employees reporting of unlawful practices. Also, there are states that protect employees who come forward and raise critical public policy concerns.

Then, comes MEDICAL WHISTLEBLOWER –

A medical whistleblower is an individual who reports healthcare wrongdoing or fraud, often taking place within the Medicare or Medicaid systems. Medical whistleblowing usually involves healthcare illegal activities and pharmaceutical misconduct. More specifically, Medicare and Medicaid whistleblowing.

Can a patient become a whistleblower?

The answer is, yes. A patient sure can become a whistleblower. In fact, it’s mostly either patient or their family members that report medical misconduct.

Whistleblowers in Medicare and Medicaid sector also help prevent detrimental practices that often end up endangering the lives of patients, including children, nursing home residents, senior citizens, dialysis patients, cancer patients, and many others. Apart from this, qui tam lawsuits also help prevent medical fraud that steals funds from many healthcare programs, or health insurance programs.

If you are aware of Medicare fraud of any size or weight, you should immediately consult with a healthcare whistleblower attorney about how to proceeds with your claim. The following are some of the common types of medical fraud –

Medicare advantage fraud and risk adjustment

Medicare Advantage plans commit misconduct when they deliberately submit risk-adjustment data that are actually ineligible or inaccurate for processing any payment under the CMS rules.

Medical loss ratio fraud

Medicare and Medicaid have become more and more private companies that now offer their benefits through Medicare Advantage Plans, Medicaid Managed Care Plans, and Medicare Part D Plans. In order to make sure that most of the funds paid by Medicare and Medicaid for ‘plans’ are spent on services instead of being pocketed as overhead or administrative expenses - Medicare and Medicaid need several ‘programs’ to maintain a minimum MLR (Medical Loss Ratio).

Reporting the Medical Loss Ratio often means making refunds to the government, programs might resort to fraud to evade any little chance of legal obligations. MLR fraud could be difficult for the regulators to identify, and this is where whistleblowers come to play their role – whether inside or outside the organization – whistleblowers can prevent the fraud from stemming.

Off-label marketing by pharmaceutical companies

Off-label marketing is an illegal practice of an organization promoting its medical devices or pharmaceuticals for uses that the FDA has not approved yet. Whistleblowers, here, play a vital role in terms of patient protection, who might get harmed as a consequence of off-label marketing by filing a qui tam lawsuit that will help expose the practices by the pharma and medical device firms.

Medical devices and implants

Both pharma and medical device companies follow certain similar sales and marketing practices that are usually discovered in the cases of pharmaceutical companies to be infringements of the False Claims Act and other states/federal statutes. As a consequence of federal/state investigations and qui tam lawsuits, medicine companies pay billions to settle allegations of Medicare and Medicaid fraud.

Upcoding

These two types of healthcare fraud are very common. Upcoding happens when a medical service provider proposes codes to private insurers, Medicare, or Medicaid for more critical diagnoses or procedures than the physician or healthcare center actually diagnosed or performed.

Medical services providers use billing codes to classify the services and procedures provided to the patients. Each of these billing codes corresponds to a specific diagnosis or service and denotes the complications of the treatment procedures. Private and government insurers use these codes to settle on how much to pay for the procedures and services. When providers tend to upcode their medical bills for Medicare and Medicaid patients, they are basically cheating those healthcare plans of required funds.

Brown, LLC is one of the reputable whistleblower law firms in the U.S.A., litigating major to minor whistleblower cases for a win. If you are considering coming forward with Medicare and Medicaid fraud information, consult with one of our Medicare and Medicaid whistleblower attorneys immediately.

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Created on Oct 6th 2021 08:48. Viewed 498 times.

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