Illegal kickbacks in managed care insurance are costly schemes that corrupt the healthcare system. When dishonest managed care organizations (MCOs) devise unlawful kickback schemes to defraud government healthcare programs, physicians base their decisions on financial gain rather than the medical needs of their patients. It’s a dangerous crime that undermines the ethics of our medical community and puts patients at risk. To help spread awareness about the severity and wastefulness of illegal Medicare and Medicaid kickbacks, let’s take a look at a recent case in which whistleblowers helped bring fraud to light.

Humana and Roche Settle False Claims Act Lawsuit for $12.5 Million

In February of 2021, pharmaceutical company Roche and Medicare Advantage insurer Humana agreed to pay $12.5 million to the U.S. government to resolve whistleblower allegations that the companies violated the anti-kickback statute. 

The case originated in 2014 when a former employee at Roche Diagnostics exposed an alleged scheme that involved Humana and Roche submitting false claims through Humana’s Medicare Advantage program.

Medicare Advantage, also known as Part C of the Medicare program, is a managed care model where the government pays private insurance companies, like Humana, premiums to insure Medicare beneficiaries. The plans are paid a capitated, or per-person, amount to provide benefits to beneficiaries who enroll in one of their plans. Payments to plans are based on demographic information and the health status of each plan beneficiary. In general, plans receive larger payments for beneficiaries with more severe diagnoses.

The whistleblower in this case, Crystal Derrick, was an account manager for Roche’s diabetes testing products. Derrick alleged Humana and Roche entered into a kickback arrangement in which Roche forgave Humana’s debts in exchange for Humana purchasing Roche products and favoring those products when selecting them for Medicare Advantage plans. Derrick alleged this arrangement was a violation of the anti-kickback statute. Under this statute, it’s a crime to “knowingly and willfully offer, pay, solicit, or receive any remuneration directly or indirectly to induce or reward patient referrals or the generation of business involving any item or service reimbursable by a Federal health care program.” 

Although the government ultimately decided not to intervene, Derrick’s case was filed under the qui tam, or whistleblower, provision, which allows any individual or non-governmental organization to file a lawsuit on behalf of the United States government. Under this provision, whistleblowers can earn a reward for exposing fraud that results in a financial loss to the federal government. As a result, Derrick is set to receive a whistleblower reward of just over $3.6 million.

Blowing the Whistle on Managed Care Insurance Fraud

Exposing wrongdoing is the best way to combat the corruption that negatively affects the greater good. Derrick’s case is a prime example of the powerful role whistleblowers play in the fight against fraud.

Our goal at DJO is to expose managed care fraud wherever and whenever possible. We work with individuals to gain information, build a case, and fight for taxpayers’ justice. In doing so, we can protect the vulnerable and make the world a safer place.

If you suspect fraud in your organization, please contact us. DJO is comprised of a highly experienced team of whistleblower experts, lawyers, and even former whistleblowers, who strive to deliver the highest monetary reward for brave individuals who have valuable information that can expose fraud. If a whistleblower’s lawsuit is successful, the reward can be up to 25% of the funds recovered. The False Claims Act also offers whistleblowers protection against job retaliation or wrongful termination.

Do you have valuable information that can help bring fraud to light? Speak to our experts today.

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