It’s easy to see how healthcare fraud can cost taxpayers and governments billions of dollars every year. And while that is not something to be ignored, healthcare fraud also significantly impacts vulnerable populations like the elderly, those with severe illnesses and disabilities, and those on fixed incomes.

When organizations take advantage of these individuals to make a profit, the American taxpayers end up footing the bill for their illegal activities. Let’s look at how healthcare fraud impacts these vulnerable populations, why shedding light on fraud is so important, and what you can do if you suspect healthcare fraud in your organization.

How does fraud impact quality of care?

When providers, medical coders, and insurance plans only care about increasing their paychecks through fraudulent activity, they aren’t putting the patient’s best interest first. Whether managed care fraud in the Medicare and Medicaid systems or more specialized like respiratory fraud or pharmaceutical fraud, patients receive misinformation and a lack of quality care.

These circumstances are most true regarding healthcare sectors like managed care, where insureds live on fixed incomes and limited resources. Some common healthcare fraud tactics include upcoding, double billing, and phantom billing, which all involve patients and insurance providers being charged for services they don’t need or for services they never even received.

These schemes may leave patients “exploited and subjected to unnecessary or unsafe medical procedures,” keeping these vulnerable populations from receiving the care they need.

Why is Shedding a Light On Fraud So Important

Not only does fraud cost taxpayers and governments significant sums of money, it can significantly impact an individual’s livelihood. When providers don’t give patients the best care possible or aren’t using their insurance funds appropriately, patients may have a more challenging time getting the care they need when and if needed.

For example, in 2022, the Department of Justice announced “charges against 36 defendants in 13 federal districts across the United States for more than $1.2 billion in alleged fraudulent telemedicine, cardiovascular and cancer genetic testing, and durable medical equipment (DME) schemes.”.

In this case, some defendants allegedly controlled a telemarketing network that lured thousands of elderly and disabled patients into a criminal scheme. The telemarketing organizations allegedly used deceptive techniques to “induce Medicare beneficiaries to agree to cardiovascular genetic testing and other genetic testing and equipment” that wasn’t medically necessary.

When telemedicine companies arrange for medical professionals to order these expensive genetic tests and durable medical equipment regardless of whether the patients need them, not only are the telemedicine companies pocketing from false claims, but the patients involved suffer from poor quality of care. For example, in many of these cases, test results or durable medical equipment were allegedly charged to patients’ insurance but were never provided to the patients or couldn’t be used by their primary care doctors.

Help Fight for Justice and Put an End to Fraud

If you suspect fraud in your organization, please contact us. Blowing the whistle on healthcare fraud is a courageous act. When you come forward, you help expose fraud for the greater good, preserving our humanity and safeguarding the systems in place to serve our nation’s citizens who are often the most vulnerable regarding healthcare.

Our DJO Whistleblower Law Group team consists of highly experienced whistleblower experts, lawyers, and even former whistleblowers, who strive to deliver the highest monetary reward for brave individuals with valuable information that can bring fraud to light.

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.

DJO will be there every step of the way to ensure you are safe and your information is confidential, so you will have confidence knowing you’re doing the right thing. If you have valuable information that can help expose fraud, we encourage you to speak to our experts today.

According to the National Library of Medicine, managed care refers to a healthcare insurance approach that integrates the financing of care and related services to keep the costs to the purchaser at a minimum while delivering what is appropriate for beneficiaries.

The government has designed this delivery system to organize and manage healthcare between Medicaid and Medicare agencies and the managed care organizations (MCOs) that accept a set payment for these services.

Unfortunately, corrupt agents often plague this healthcare sector with fraud that places a heavy burden on taxpayers and diminishes the level of care administered to the individuals in those healthcare programs.

In this article, we list some of the most common managed care fraud practices to look out for in 2023, how to identify them, and what to do if you suspect fraud in your organization.

What is Managed Care Fraud?

While managed care programs have Special Investigative Units (SIUs) to search for and prevent potential fraud, waste, and abuse, managed care fraud still occurs. Fraud occurs when Managed Care Organizations (MCOs) attempt to cheat the system through actions like double-billing, kickbacks for providers, falsifying patient records, and miscoding or upcoding patient diagnoses to charge a higher amount to managed care insurance.

When MCOs illegally manipulate the healthcare system, they effectively steal billions of taxpayer dollars designated to fund these healthcare programs. Not to mention, the patients who use these programs suffer from care that is not adequate or accurate to what their provider may bill.

Most Common Trends in Managed Care Fraud

When it comes to managed care, fraud can occur in several unique and specific ways. Let’s look at some of the most common trends in 2023 and how the government defines these schemes as fraudulent.

• Medical Loss Ratio (MLR) Fraud occurs when healthcare plans knowingly file false reports to skew the perception of funds spent on patient care and quality improvement measures instead of administrative expenses and profits. The MLR rule, implemented by the Patient Protection and Affordable Care Act (ACA), mandates that funds are spent primarily on healthcare, significantly limiting the ratio of funds allocated to the insurance company’s profit.

• Adverse Selection occurs when “an insurance company extends insurance coverage to an applicant whose actual risk is substantially higher than the risk known by the insurance company.” But in the case of managed care, some organizations will choose their insureds based on previously known information and, in turn, discriminate against individuals that fall out of their desired group.
• Enrollment Fraud occurs when MCOs enlist enrollment practices where healthy patients are “recruited” to join certain MCOs in a practice known as “cherry picking.” These patients are used to skew the data and are often illegally compensated for participating in the program.
• Healthcare Effectiveness Data & Information Set (HEDIS) Fraud happens when MCOs falsify their quality and effectiveness data to give the impression that they are more highly rated than they truly are. Doing so allows them to qualify for more ACA incentives and bonus programs that they then illegally pay out to administrators and providers in the form of kickbacks.
• Risk Adjustment Fraud is similar to adverse selection and enrollment fraud. However, risk adjustment fraud occurs when MCOs seek to scam the healthcare system by inflating the risk profile of patients. This can involve a physician, or a third-party medical coding company contracted to the MCO. Because risk adjustment payments are calculated based on members’ diagnoses, plans have developed many schemes aimed at “upcoding” or exaggerating the severity of members’ diagnoses or medical conditions to cause the government to pay out more risk adjustment reimbursement than is warranted.

What to Do if You Suspect Fraud

If you believe that any of these actions are occurring in your organization, rest assured that you are not alone. Managed care fraud occurs daily, stealing money from American taxpayers and disrupting service for the millions relying on government programs for healthcare. For this reason, whistleblowers play an important role in the fight against fraud.

If you are considering blowing the whistle, we encourage you to reach out to our team of professionals. We can help develop a plan to gain information, build a case, and fight for justice. Our experienced team of attorneys can help answer your questions and guide you through the process to protect your privacy and earn you the monetary reward you deserve for your bravery.

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.

Medical Loss Ratio (MLR) fraud occurs when plans knowingly misrepresent a proportion of funds spent on patient care and quality improvement measures as opposed to administrative expenses and profits. In this article, we take a deeper dive into MLR fraud and how it impacts our healthcare system.

What is Medical Loss Ratio?

The Affordable Care Act (ACA) requires managed care insurance plans spend a minimum proportion of premium revenue on patient care and quality improvement initiatives in order to limit the amount that can be allocated towards administrative expenses and profits. This is to ensure that taxpayer dollars are being used for healthcare rather than as extra income for insurance companies. Unfortunately, some plans commit fraud by falsely reporting the amount of money spent on patient care and quality improvement.

Identifying MLR Fraud

MLR fraud can be difficult to identify because it can take so many forms. Here’s a look at some common examples:

• Falsely classifying administrative expenses as claims-related expenses.
• Hiding or misallocating revenue from contracts.
• Making excessive or duplicate payments to providers to increase medical services spending.
• Paying provider claims that should have been denied under Medicare rules.
• Making MLR look higher than it is by reporting false information regarding profits or medical expenses to the government.

Reporting MLR Fraud

Whistleblowers are essential to detecting and reporting MLR fraud. They can help protect and bring justice to the healthcare system by providing information on the complicated, hidden conduct that managed care organizations use to defraud the government. For example, in 2012, the government ordered Florida-based health plan company, WellCare, to pay $137.5 million to resolve four lawsuits alleging violations of the False Claims Act after a former employee secretly recorded WellCare executives discussing ways to double bill for patient services in order to avoid returning money to Medicaid and other programs in various states. As a result, the whistleblower received an award of $20.75 million for helping bring justice to the healthcare system.

Blowing the Whistle on MLR Fraud

Like other types of fraud in managed care insurance, MLR fraud steals money from American taxpayers and the millions you rely on government health programs for care. This is why whistleblowers play such an important role in the fight against fraud.

If you are considering blowing the whistle, experienced healthcare fraud attorneys can help answer your questions and guide you through an otherwise arduous situation and work to earn you the monetary rewards you deserve.

Our goal at DJO is to expose 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.

With decades of combined whistleblower experience and more than 200 cases investigated and filed, our team has been involved directly with recouping hundreds of millions of dollars for US taxpayers. We firmly believe in doing what is right and will work alongside you every step of the way in support, as together, we deliver justice.

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.

Medicare Advantage is a type of health insurance plan offered by private companies contracted by the government. Also known as Medicare Part C, Medicare Advantage was designed to incentivize health insurers to develop innovative ways to improve care while decreasing costs. However, a report by the New York Times shows many of the large insurers that offer these plans have been accused of fraud. In this article, we take a more in-depth look into Medicare Advantage fraud and the role whistleblowers play in exposing it.

Medicare Advantage Fraud on the Rise

The government provides set payments to Medicare Advantage insurers for every enrollee, with additional payments for patients with more health needs. However, many major insurers have been accused of exploiting the system in order to collect more money from the government. Federal audits released late last year reveal widespread overcharges and other errors in payments to Medicare Advantage, with some plans overbilling the government more than $1,000 per patient a year on average. Now, a program that was designed to help lower healthcare spending has become more expensive than the traditional government program it was supposed to improve. To highlight the high cost and importance of exposing Medicare Advantage fraud, let’s take a look at some notable cases.

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. This settlement resolves allegations that Sutter knowingly submitted inaccurate diagnosis codes for beneficiaries enrolled in Medicare Advantage Plans. According to the government’s allegations, Sutter Health knowingly submitted unsupported diagnosis codes for certain patient encounters for beneficiaries under its care. As a result, these unsupported diagnosis codes caused inflated payments to be made to the plans and to Sutter Health.

Freedom Health Agreed to Pay $32.5 Million to Settle False Claims Act Allegations

In May of 2017, Florida-based provider of managed care services Freedom Health, agreed to pay $32.5 million to resolve a whistleblower lawsuit alleging they violated the False Claims Act by engaging in illegal schemes to maximize their payment from the government in connection with their Medicare Advantage plans. According to the government, Freedom Health submitted or caused others to submit unsupported diagnosis codes to The Centers for Medicare & Medicaid Services (CMS), which resulted in inflated reimbursements from 2008 to 2013.

The High Price of Medicare Advantage Fraud

When an organization exploits government-funded programs, like Medicare, they take money directly out of the US taxpayer’s pockets. Miscoding patient diagnoses in order to qualify for additional funds not only steals from American taxpayers but also the millions of Americans who rely on these plans for care. This is why we must work together to expose fraud wherever possible.

Blowing the Whistle on Medicare Advantage Fraud

Whistleblowers play a major role in the fight against corruption, fraud, and wrongdoing in Medicare Advantage fraud. These brave individuals have helped save millions in public funds and the integrity of our healthcare system.

Our goal at DJO is to expose 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.

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.

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.

Managed care is a form of health insurance that aims to reduce costs and improve quality of care by leveraging contracts with care providers and medical facilities to increase efficiency of coordinated patient care. Within the system, federal and state governments contract private insurers, also known as Managed Care Organizations (MCO), to provide health insurance benefits to government beneficiaries enrolled in Medicare and Medicaid plans. 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 (also known as risk scores) of each plan beneficiary. In general, plans receive larger payments for beneficiaries with more severe diagnoses.

Unfortunately, corrupt MCOs involved in managed care fraud will often game the reimbursement system to retain more than their fair share of government funds by miscoding patient diagnoses and inflating risk scores. In this article, we take a look at one of the most common ways dishonest organizations commit fraud in managed care insurance and its massive chain of impact.

What Is Risk Adjustment Fraud and What Does It Look Like in Managed Care?

Risk adjustment fraud occurs when MCOs, coding companies, and others contracted to work with other government insurers seek to game the healthcare system by inflating the risk profile of patients. This can involve a physician IPA or even a third-party medical coding company that is contracted by the MCOs. Because risk adjustment payments are calculated based on members’ diagnoses, plans have developed a number of schemes aimed at “upcoding” or exaggerating the severity of members’ diagnoses or medical conditions to cause the government to pay out more risk adjustment reimbursement than is warranted.

Let’s take a look at an example.

In July of 2021, the federal government intervened in six complaints alleging Kaiser Permanente violated the False Claims Act by submitting inaccurate diagnosis codes for its Medicare Advantage Plan enrollees in order to receive higher reimbursements. According to the DOJ, Kaiser allegedly pressured its physicians to add risk-adjusting diagnoses that patients did not actually have and/or were not considered or addressed during the encounter in order to increase Kaiser’s Medicare reimbursements.

Impact of Risk Adjustment Fraud

Risk adjustment fraud has a massive chain of impact that affects not only the millions who rely on these health programs for care but also the American taxpayers. When dishonest providers commit fraud, it siphons money from legitimate government-funded programs and contributes to rising healthcare costs. It’s a crime against you, the government, and all the other honest medical professionals.

Speak Out Against Risk Adjustment Fraud

Whistleblowers play a major role in the fight against corruption, fraud, and wrongdoing in managed care. These brave individuals have helped save millions in public funds and the integrity of our healthcare system.

For those considering blowing the whistle, consulting the right fraud attorney is an important first step. The right law group can help keep you protected, guide you through the entire process, and help you earn a potential reward for doing the right thing.

Our team at DJO consists of highly experienced whistleblower experts, lawyers, and even former whistleblowers, who strive to deliver the highest monetary reward for brave individuals with valuable information that can bring fraud to light.

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.

DJO will be there every step of the way to ensure you are safe and your information is confidential, so you will have confidence knowing you’re doing the right thing. If you have valuable information that can help expose fraud, we encourage you to speak to our experts today.

Fraud in managed care is an unfortunate reality that costs the government and taxpayers billions of dollars each year. Schemes like falsifying patient records, upcoding, cherrypicking, and enrollment fraud siphon money away from the 160 million Americans enrolled in legitimate government healthcare programs, increase taxes, and contribute to rising healthcare costs. This is why it’s so important to expose wrongdoing and report managed care insurance fraud whenever possible.

Exposing wrongdoing is the best way to fight the corruption that negatively affects the greater good. While choosing to become a whistleblower may feel scary, breaking down the process step-by-step and knowing what to expect can help alleviate some of the apprehension of your decision to report fraud. If you plan on making the decision to become a whistleblower, read this article to learn more about the process and what to expect.

1. Get Guidance From a Fraud Expert and/or Whistleblower Attorney

The first step of the process is talking to a fraud expert and/or whistleblower attorney to confidentially review what you witnessed. This is the safest and most secure way to expose fraud. It’s best to consult with a knowledgeable whistleblower attorney who has experience in managed care insurance fraud because they will offer:

• Confidential consultations
• Give you advice on how to proceed
• Guide you through the process of becoming a whistleblower
• File your claim with the Government
• Support you through the investigation
• Help you potentially secure a financial reward for bringing injustices to light

2. Present Your Evidence

Once you’ve talked to the experts and have selected your legal representation, your lawyers will ask questions about the incident to extract all valuable information that will be used against the defendant. During this time, you’ll want to make sure you present all of your evidence. Some examples include:

• All internal communications
• Emails
• Texts
• Documents
• Powerpoint presentations
• Email communications
• Internal studies
• Billing records
• Test results

Sharing all of your evidence with your legal representation is crucial to your case. The more evidence you have, the stronger your case will be. Your lawyers will then review your evidence, investigate further, and begin building the case.

3. File a Claim

Under the federal False Claims Act, a whistleblower must file a qui tam complaint in court and submit it to the government, along with a Disclosure Statement that details the alleged fraud. It’s important to note that your representation will assist you in submitting the Disclosure Statement and other paperwork necessary for filing your report.

Once your claim is submitted, you and your attorney will likely meet with government attorneys to discuss your allegations. These initial meetings often influence the direction of your case, so it’s important to be completely honest and present your evidence as best you can.

4. Investigating Your Claim

As part of its investigation, the government will likely interview witnesses, examine evidence, review documents and also request documents relating to the alleged fraud. During this time, your experienced whistleblower attorney will be by your side to make sure you provide whatever information the government requests. Your attorney will also be there to remind you not to discuss your case with anyone other than your lawyer and the government officials assigned to your case while it’s under seal.

Keep in mind investigations often take a very long time–typically several years or more. Therefore, having the right representation who can guide you through the entire process is invaluable.

5. Following the Investigation

After the government has concluded its investigation, it has the opportunity to decide whether it wants to bring a formal legal action against the accused. If the government does decide to intervene and take over the prosecution, the case will then proceed through the process of litigation or settlement.

6. Earn a Potential Whistleblower Reward

Whistleblowers who bring original information to the government can be entitled to receive a share of the government’s recovery. An individual (called a false claims plaintiff or relator) who is an original source of information can sue for violations of the FCA. If the government prosecutes, a relator can receive up to 25% of the total amount recovered.

Help Blow the Whistle on Managed Care Insurance Fraud

Our goal at DJO is to expose managed care insurance 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 managed care insurance fraud within your organization or with someone you work with, 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. Additionally, 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.

Unfortunately, Medicare, Medicaid, and other government healthcare programs are impacted by fraud. However, we’ve seen a number of successful managed care fraud cases resulting in settlements and whistleblower rewards over the last few years.

In managed care, federal and state governments contract private insurers, also known as Managed Care Organizations (MCO), to provide health insurance benefits to government 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. This is typically when fraud occurs. MCOs involved in managed care fraud will often game the reimbursement system and retain more than their fair share of government funds by falsifying patient records and miscoding patient diagnoses.

Managed care fraud takes money away from legitimate government healthcare programs and is a contributing factor to the rising healthcare costs in the United States. Let’s take a look at three managed care fraud cases and how whistleblowers play an integral role in exposing fraud in the industry.

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 health care services provider Sutter Health. The settlement resolves allegations that Sutter knowingly submitted inaccurate diagnosis codes for beneficiaries enrolled in Medicare Advantage Plans.

The whistleblower lawsuit was filed against Sutter Health and its affiliates in 2015 by Sutter employee Kathleen Ormsby and alleged that the company had massively overbilled the Medicare Advantage program over a period of approximately six years. As the original whistleblower, Ormsby may receive 15 to 30 percent of the settlement.

CareCore Admits to Improperly Authorizing Over 200,000 Procedures Paid For With Medicare and Medicaid Funds

In May of 2017, CareCore National, LLC agreed to pay $54 million to settle a whistleblower lawsuit alleging the benefits management company authorized medical diagnostic procedures for Medicare and Medicaid patients without properly assessing whether the procedures were in fact necessary or reasonable. According to the DOJ, CareCore authorized over 200,000 diagnostic procedures between 2005 and 2013 which had not been properly reviewed and were unnecessary or inappropriate.

The whistleblower who filed the qui tam lawsuit against CareCore had been employed as a clinical reviewer, but had been instructed to fraudulently approve diagnostic test requests without proper review.

Freedom Health Agreed to Pay $32.5 Million to Settle False Claims Act Allegations

In May of 2017, Florida-based provider of managed care services Freedom Health, agreed to pay $32.5 million to resolve a whistleblower lawsuit alleging they violated the False Claims Act by engaging in illegal schemes to maximize their payment from the government in connection with their Medicare Advantage plans. According to the government, Freedom Health submitted or caused others to submit unsupported diagnosis codes to The Centers for Medicare & Medicaid Services (CMS), which resulted in inflated reimbursements from 2008 to 2013.

Shining a Light on Managed Care Fraud

These cases are 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.

Managed care fraud is an unfortunate reality that costs the government and taxpayers billions of dollars each year. Managed Care Organizations (MCO) involved in managed care fraud game the system by falsifying patient records and miscoding patient diagnoses in order to qualify for additional funds. This type of fraud takes money away from legitimate government healthcare programs and is a contributing factor to the rising healthcare costs in the United States.

Exposing the organizations and individuals committing these crimes is the best way to fight managed care fraud. Individuals with knowledge of fraud committed by MCOs can report wrongdoing under the False Claims Act and receive a percentage of the government’s recovery as an incentive for their information.

Let’s take a look at some common examples of managed care schemes and how whistleblowers can help stop fraud.

Common Managed Care Fraud Schemes

Whistleblowers and the government have uncovered several schemes MCOs and others in business with MCOs, have used to defraud the healthcare system. Here are some examples of fraudulent schemes in managed care:

• Medical Loss Ratio (MLR) Fraud occurs when plans knowingly misrepresent a proportion of funds spent on patient care and quality improvement measures as opposed to administrative expenses and profits. The MLR rule, implemented by the Patient Protection and Affordable Care Act (ACA), mandates that funds are spent primarily on healthcare, effectively limiting the ratio of funds that can be allocated to the profit of the insurance companies.
• Healthcare Effectiveness Data & Information Set (HEDIS) Fraud occurs when plans manipulate their quality and effectiveness metrics to enhance their ratings and receive unearned benefits from the ACAs quality incentive program. By falsifying a higher rating, plans receive Quality Bonus Payments (QBP) to which they are not entitled.
• Risk Adjustment Fraud occurs when MCOs and others contracted to work with other government insurers seek to game the healthcare system by inflating the risk profile of patients. This can involve a physician IPA or even a third party medical coding company that is contracted to the MCO’s. Because risk adjustment payments are calculated based on members’ diagnoses, plans have developed a number of schemes aimed at “upcoding” or exaggerating the severity of members’ diagnoses or medical conditions to cause the government to pay out more risk adjustment reimbursement than is warranted.
• Enrollment Fraud occurs when MCO’s enroll members outside of the established pre-approved periods using false data to qualify the member.
• Adverse Selection occurs when operators of managed care plans try to minimize risk by choosing to enroll a larger pool of healthy people choosing managed care and avoiding less healthy people choosing more generous plans.

Help Blow the Whistle on Managed Care Fraud

These are only a few examples of the schemes that occur in managed care. Whistleblowers play an important role in exposing fraud and holding organizations and wrongdoers accountable.

Our goal at DJO Law Group 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.