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Johns Hopkins University and one of its teaching hospitals agreed to pay more than $2.6 million in February 2004, to settle a federal lawsuit alleging that they overbilled the National Institutes of Health for addiction research and other projects. The university and its hospital agreed to pay $2.1 million in addition to $587,000 already refunded, but they did not admit any wrongdoing. Faye Grau, 64, the secretary who filed the initial complaint, received $439,000 of the settlement under the Federal False Claims Act. Lawrence Livermore Lab and the University of California agreed to a $3.9 million settlement for mischarging on energy research projects. The case began in the mid-1990s when Michelle Doggett, a manager of cooperative research and development agreements (CRADA) told supervisors and university investigators of improper charges to energy research accounts. She said some energy-research managers treated the CRADA funds as "funny money." Doggett said managers began alienating her, reassigning her from overseeing research funds and eventually driving her to resign. Last year, the university paid her $1 million to settle her claims of whistleblower retaliation. Former Norwalk Hospital chief financial officer Raul Lopez, alleged in his suit that between 1994 and 1999 the hospital billed for costs not allowed under Medicare rules or unrelated to patient care. The case settled for $4.1 million and whistleblower Lopez will receive about $700,000 from the settlement. In June 2001, a whistleblower was awarded nearly $1.1 million after seven Florida Hospitals agreed to pay $5 million to settle Medicare fraud charges stemming from a whistleblower lawsuit. The government and whistleblower claimed that the hospitals billed for surgical procedures they knew that the procedures were non-reimbursable. The hospitals included: Holy Cross Hospital in Ft. Lauderdale, Fl; Miami Heart Institute in Miami, Fl; South Miami Hospital in Miami, FL; and Mt. Sinai Hospital in Miami, FL. Back to Top HCA - over $1,600,000,000 Various whistleblowers divvied up over $100 million from HCA Inc. (formerly known as Columbia/HCA and HCA – The Healthcare Company) from two settlements totaling over $1.6 billion. In December 2000, a $731 million partial settlement was recovered from HCA's frauds on the taxpaying public included: billing for lab tests that were not medically necessary and not ordered by physicians, "upcoding" medical problems in order to get higher reimbursements for more serious medical issues, billing the government for advertising under the guise of "community education," and billing the government for non-reimbursable costs incurred in the purchase of home health agencies around the country. In June 2003, HCA agreed to pay the United States $631 million to resolve HCA's civil liability for false claims including cost report fraud and the payment of kickbacks to physicians. In a separate administrative settlement with the Centers for Medicare & Medicaid Services (CMS), HCA agreed to pay an additional $250 million to resolve overpayment claims arising from its cost reporting practices. TAP [Taketa-Abbott Pharmaceutical] Pharmaceutical Products Inc. - $559,483,560 In October 2001, TAP Pharmaceutical Products Inc. agreed to pay $875 million to resolve criminal charges and civil liabilities in connection with fraudulent drug pricing and marketing of Lupron, a drug sold for the treatment of prostate cancer. Of this amount, $559,483,560 was recovered under the False Claims Act. Abbott Labs -- $400,000,000 In July of 2003, Abbott/CG Nutritionals, a unit of Abbott Laboratories, Inc., agreed to pay $400 million under the False Claims Act to resolve civil claims. Back to Top - Receiving federal funds to construct something and not complying with the construction requirements.
- Receiving federal funds to perform a service and not completing the service as required by the grant.
- Noncompliance with federal grant requirements such as labor, employment standards and environmental standards.
- Noncompliance with federal grant requirements such as receiving illegal referral fees, kickbacks, and bid-rigging.
- City or county contractors being offered procurement sensitive information.
- Mis-reporting annual performance for HUD certifications.
- Failing to comply with federal accounting and cost reporting requirements. For example, improper allocation of overhead.
- Grant applications containing false or inaccurate statements such as, misstatements concerning prior research.
- "Cleaning," manipulating and misinterpreting data on research reports and interim reports.
- Improper accounting for indirect research costs.
- Improper inclusion or charging of non allowable expenses to federal grants or loans such as for "phantom" employees who do not actually work on that grant or for hours that were not actually worked.
- Scholarship applications containing false or inaccurate statements, such as failure to confirm U.S. citizenship for Pell Grant applicants.
- Double billing.
Hospitals, nursing homes, doctors, home health care agencies, pharmacies, and laboratories that seek and receive reimbursement for Medicare and Medicaid funds are Government contractors subject to the False Claims Act. Reporting such fraud not only improves the healthcare for patients and loved ones, it also helps ensure that public Medicare and Medicaid monies are properly spent in accordance with the law and good medical practice.
Violations can include: - Substandard care. Healthcare workers and families of nursing home or hospital patients should pay particular attention that the quality of services provided meets federal standards.
- Performing inappropriate or unnecessary procedures.
- A drug or equipment supplier completing a Certificate of Medical Necessity (CMN) instead of the physician.
- Offering free services or supplies in exchange for your Medicare or Medicaid number.
- "Defective Testing": When a test or part of a test was not performed because of technical trouble, such as an insufficient or destroyed sample or machine malfunction, but is billed for anyway.
- "Reflex testing": Automatically running a test whenever the results of some other test fall within a certain range, even though the reflex test was not requested by a physician.
- Misrepresenting the type of services rendered.
- "Phantom Billing": Billing for tests or services not performed or for equipment/supplies never ordered.
- Billing for new or expensive equipment but providing the patient used or cheap equipment.
- "Code Jamming": Inserting fake diagnosis codes to get Medicare/Medicaid coverage.
- "Unbundling": Using two or more Current Procedural Terminology ("CPT") billing codes instead of one inclusive code where rules and regulations require "bundling" of such claims.
- "Double Billing": Charging more than once for the same service, for example by billing using an individual code and again as part of an automated or bundled set of tests. Also submitting multiple bills in order to obtain a higher reimbursement for tests and services which should have been submitted as a single bill.
- "Up Coding": Inflating bills by using diagnosis billing codes that indicate the patient experienced medical complications and/or needed more expensive treatments. This can include:
- billing for complex services when only simple services were performed,
- billing for brand-named drugs when generic drugs were provided,
- listing treatment as having been for a more complicated diagnosis than was actually the case.
- "Phantom": Expensing employees or hours worked that do not exist.
- Improper Reports: Submitting false cost reports seeking higher Medicare reimbursements than permitted by actual facts.
- Accounting Fraud, such as failing to comply with accounting and cost reporting requirements, or example mis-allocation of overhead.
- Routinely waiving patient co-payments.
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Healthcare workers and families of those in nursing homes should pay particular attention to services provided so as to ensure that family members and patients receive the quality of care required by law and for which patients are entitled. Back to Top Defense fraud can include misuse of ordinary items like computers, uniforms, vehicle parts and office equipment. Where the federal contract involves the procurement of a fleet of aircraft, vessels, or other vehicles or thousands of weapons like cruise missiles, the Government enters into a “prime contract” with a manufacturer or supplier. The prime contractor, in turn, enters into subcontracts with hundreds of other companies that manufacture and supply components or provide essential military goods and services. See, Other Types of Fraud. All of these contractors may be subject to the False Claims Act, even though they may not directly contract with the Government. Back to Top
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