Managed care insurance fraud is an unfortunate reality that affects taxpayers, the government, and the millions of individuals enrolled in government-funded health plans. It’s a costly crime that steals at least $308.6 billion from American consumers every year. We must all work together to put a stop to schemes like upcoding and phantom billing by reporting fraud wherever and whenever possible. If you suspect managed care insurance fraud, here’s what you need to know about reporting your allegations and the information you need to support your case.

What Kind of Evidence Do I Need?

When coming forward with information about fraud, individuals want to be assured that they are receiving the highest possible reward for the information they are providing. How can one ensure that their information is applicable?

Some factors for ensuring your information is applicable include how extensive and detailed the information is about the reported fraud, whether the fraud involved a serious safety issue and the quality of the assistance the whistleblower and lawyers provide to the case. It is important to note that an individual should not wait long to report fraud, as the case, and the potential reward will go to the person who first shared the information. While you don’t have to witness the fraud firsthand, you do need physical evidence to show that misconduct actually occurred. This can include:

  • Documented meetings
  • Phone conversations
  • Emails
  • Research
  • Marketing and sales materials
  • Patient-specific information
  • Billing records
  • Test results

Documentation of fraudulent activities is important when bringing a potential case. The more information and documentation you have, the stronger your case will be. Let’s take a look at a case in which a whistleblower accused her former employer of knowingly submitting false health status information about beneficiaries to boost risk scores and drive up reimbursement.

Sutter Health and Affiliates to Pay $90 Million to Settle False Claims Act Allegations of Mischarging the Medicare Advantage Program

In August of 2021, the government announced a $90 million False Claims Act settlement with California-based healthcare services provider Sutter Health. The settlement stems from a whistleblower lawsuit filed by former Sutter employee, Kathleen Ormsby. After Ormsby was hired in 2013, she began comparing benefit codes with patient medical records and discovered high error rates suggesting Sutter was getting overcompensated for services by the government. When Ormsby notified her superiors, her audits were shut down, and Sutter continued their practices. In 2015, Ormsby reported the discrepancies and filed a whistleblower lawsuit under the False Claims Act. As the first complainant in the whistleblower lawsuit, Kathleen Ormsby is set to receive between 15% and 30% of the settlement.

Blowing the Whistle on Managed Care Insurance Fraud

The Sutter case is a prime example of the seriousness of managed care fraud and how powerful whistleblowers are in enacting change and demanding justice.

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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