ATTORNEY NEWSLETTER
Allegations of Unsupported Diagnosis Codes
False Claims Allegedly Submitted In Federal Employee Health Insurance Programs
Hearing Loss Diagnoses Allegedly Lacked Back-Up Documentation
Year in and year out, individuals bring more enforcement efforts against companies defrauding the government than the government itself brings. Many of the cases brought by these individuals involve fraud in the health care field, and sometimes the fraud occurs in the very health care program the government sponsors for its own employees, as a recent settlement discussed below illustrates. Whatever the type of fraud and government program involved, cases are brought under the False Claims Act, (“FCA”), 31 U.S.C. § 3729 et seq. and are known as “qui tam actions.” Qui tam actions recover billions for the government every year. The FCA authorizes substantial awards to the plaintiffs, known as qui tam relators (whistleblowers), for bringing and prosecuting these and other cases concerning fraud on the government. 31 U.S.C. §3730 (d). Frequently, relators are current or former employees, representatives or agents of the businesses committing the alleged fraud. If you have credible information of fraud against the government in violation of the FCA here in San Francisco or elsewhere in California, call us today at (415)441-8669 and we can help. Our toll-free number is 1-888-50EVANS (888-503-8267).
Recent FCA And Common Law Fraud Settlement[1]
The U.S. Department of Justice (DOJ) recently announced that a hearing aid company has agreed to pay $34.37 million to resolve allegations that it submitted or caused the submission of claims for hearing aid devices for reimbursement to the Federal Employees Health Benefits Program (FEHBP) that contained unsupported hearing loss diagnosis codes. The FEHBP, administered by the U.S. Office of Personnel Management (OPM), is the largest employer-sponsored group health insurance program in the world. It provides health benefits through various health insurance carriers and covers over eight million federal employees, retirees, former employees, family members and former spouses. FEHBP requires that claims for hearing aid devices include a hearing loss-related diagnosis code. These diagnosis codes must be supported by a hearing loss diagnosis, which is typically based on a hearing test performed by a health care provider. The United States alleged that for a four-year period the defendant included unsupported hearing loss-related diagnosis codes on claims for hearing aid devices that the company submitted to the FEHBP on invoices — called superbills — that the company provided to FEHBP beneficiaries to obtain reimbursement. The government further alleged that the company continued to include these unsupported hearing loss-related diagnosis codes on claims and superbills — even after completing an internal review of its billing and coding practices— resulting in the company knowingly submitting or causing the submission of false claims for payment to the FEHBP.
How A Qui Tam Action Begins
Individuals with original and credible information of false claims begin FCA qui tam cases by filing a complaint under seal in the federal court. At the same time, the relator submits a disclosure to the DOJ outlining the material evidence the relator has of the alleged false claims. 31 U.S.C. § 3730(b). The seal period of the complaint lasts 60 days during which the DOJ investigates the claims. 31 U.S.C. § 3730(b)(2). (If necessary, the government can, and often does, extend the 60-day period during which the allegations are kept under seal.) If the government decides to intervene in the case, the government essentially takes over the litigation. 31 U.S.C. § 3730(c)(1). If the government declines to intervene, the relator may proceed with the litigation on his or her own. 31 U.S.C. § 3730(c)(3).
Contact Us
If you have credible information of government fraud here in San Francisco or elsewhere in California, call Ingrid M. Evans at (415) 441-8669, or toll-free at 1-888-50EVANS (888-503-8267) or by email at <a href=”mailto:info@evanslaw.com”>info@evanslaw.com</a>. In addition to FCA and CFCA whistleblower cases, Ingrid and Evans Law Firm, Inc. also handle bank fraud whistleblower cases under FIRREA/FIAFEA, commodity trading and securities fraud under the Commodities Futures Trading Commission Whistleblower Program and the Securities and Exchange Commission Whistleblower Program, and tax fraud under the Internal Revenue Service Whistleblower Program.
[1] Evans Law Firm, Inc. was not involved in the case in any way.
