Healthcare Fraud Whistleblower

Healthcare Fraud: Pharmaceutical Companies

Pharmaceutical companies can be found liable in whistleblower actions under the False Claims Act for Medicare and Medicaid fraud. Medicare or Medicaid fraud occurs not only when the pharmaceutical company directly defrauds the Government, but also when the fraud is indirect. Common whistleblower actions against pharmaceutical companies have targeted actions such as:

  • Paying kickbacks and inducements to physicians
  • Paying kickbacks and inducements to hospitals
  • Paying kickbacks and inducements to pharmacists to prescribe or otherwise favor their drugs
  • Off-label marketing
  • Misrepresenting the "best price" or the "federal ceiling price" charged to the Medicare and Medicaid program
  • overcharging for drugs under certain federal program
  • Manufacturing or distributing substandard or adulterated drugs
  • Manufacturing or distributing
  • Providing false data to or omitting or withholding negative data from the FDA during the FDA approval process
Healthcare Fraud: Medical Necessity

The overwhelming majority of healthcare providers are honest and primarily concerned with providing quality healthcare, but not all. Healthcare providers are not legally allowed to bill or charge Medicare or Medicaid for services or procedures that were not medically necessary. If a healthcare provider charges Medicare or Medicaid for services or procedures that were not medically necessary, a potential whistleblower can obtain a reward under the False Claims Act for those false billing practices.

Healthcare Fraud: Fraudulent Cost Reports

Similar to whistleblower actions when healthcare providers falsely bill for procedures that were not medically necessary, healthcare providers can be liable for other fraudulent billing practices. Medicare reimburses healthcare providers for certain other costs, such as capital improvements, new medical equipment, or improved infrastructure. If a healthcare provider falsely claims or bills for fictitious or inflated costs, this is healthcare fraud. A potential whistleblower can obtain a reward under the False Claims Act for those false billing practices.

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