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Medicare Fraud in Oklahoma
Government Fraud Lawyers

LOCAL & CONFIDENTIAL:    Confidentially talk with an Oklahoma-based attorney today:    405-702-9900

Medicare & Medicaid Fraud

Most medical providers (doctors, hospitals, etc.) are individuals that bill Medicare and Medicaid for only the goods and services they provide.  There are, however, some that abuse the system by overbilling, up-coding, and defrauding the Medicare system.  When this happens, it's all of our collective tax dollars being stolen.

The amount of potential recoveries and rewards is huge and widespread. 

  • During 2009 and 2010, the U.S. Justice Department recovered more than $5 billion under the False Claims Act, the largest amount in any two-year period in history. 
  • The U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius and U.S. Associate Attorney General Thomas J. Perrelli announced on January 24, 2011, a new report showing that the government’s health care fraud prevention and enforcement efforts recovered more than $4 billion in taxpayer dollars in Fiscal Year (FY) 2010.  This is the highest annual amount ever recovered from people who attempted to defraud seniors and taxpayers.
  • On February 17, 2011, the U.S. Department of Justice announced it charged 111 individuals for more than $225 million in false billing.

The federal and Oklahoma State governments are extremely serious in their desire to catch those abusing the system, but those working for the government don't have the resources to do it all themselves.  They rely on you, and the legal system is set up to handle these matters.

Different Types of Medicare Fraud

There are different types of Medicare and Medicaid Fraud, all sharing one common theme: the provider does something that results in more payment from Medicare to the provider than should be paid.  There are specific laws that apply to Medicare and Medicaid fraud, some of which require the offending provider to pay a civil fine, and others that are criminal in nature and may include time in jail.  Some of the more common types of fraud found in the healthcare industry are as follows:

Kickbacks & The Anti-Kickback Law

  • Kickbacks:  Kickbacks occur when a medical provider refers a patient to another medical provider and unlawfully receives some form of compensation for the referral.  For example, if a physical therapy center pays a doctor for each patient the doctor refers to the center, this could be an illegal kickback.  The Anti-Kickback laws are criminal in nature and strictly prohibit kickbacks in the U.S. healthcare system.

    Self-Referral, The Stark Law

  • Stark Law:  The Stark Law is named after Congressman Pete Stark and is intended to stop providers (specifically, physicians) from referring patients for healthcare services from another entity that the referring physician owns.  At its core, the "Stark Law" is a law against self-referral and is civil in nature, imposing steep fines for unlawful self-referrals.
     
  • The False Claims Act

  • False Claims Act:  The False Claims Act (FCA) is a law which makes submitting a false claim to the government an unlawful act.  A "false claim" can include a claim for goods or services that either weren't provided at all, or were provided at a lower service level than is being claims (e.g., "up-coding").  (see also, Whistleblowers)
     
  • False Certification

  • False Certification:  False certification claims are situations where an organization certifies that it has complied with all applicable laws in order to be a Medicare provider, but really has not complied.  For example, if a hospital certifies that it has complied with all the Anti-Kickback and Stark Laws, but it is actually paying doctors based on how much business they bring to the hospital, then the hospital has made a false certification.  These claims are potentially devastating for the organization because, if an entity makes a false certification, the government can then allege that every claim it made to Medicare was a False Claim.

Qui Tam, "Whistleblowers"; Financial Rewards

The government wants, and needs, your help in combating Medicare and Medicaid Fraud, and they have provided a sizable financial incentive and legal protections for you to come forward.

The specific law is sometimes called "Qui Tam" (pronounced "Key-Tam").  The phrase "qui tam" is really a shortened version of the Latin phrase "qui tam pro domino rege quam pro se ipso in hac parte sequitur," which means "he who sues in this matter for the king as well as for himself."

What it means in practical terms is that the government will pay you if you are an individual who knows of and brings and action for government fraud.  As a tax-paying individual, you are being cheated by every action of fraud on the government, so a qui tam lawsuit is one where you go after the government defrauder on behalf of yourself and the government. 

The amount of money a whistleblower can receive from a successful claim can be substantial, ranging from approximately 10-30% of the amount the government recovers.  Depending on what claims and charges are found against the defrauder, penalties can include not only the amount of money actually defrauded, but also penalties ranging from $5,000 to $25,000 per claim sent to the government.  Additionally, in some instances, the amount of the penalty is tripled.  It is, therefore, not uncommon for penalties to be assessed in amounts in the millions, tens of millions, and even hundreds of millions of dollars.

What the Government is Looking For

Qui tam claims can result from many situations, but some of the more typical include:

  •  A healthcare provider (e.g., doctor, hospital, physical therapy, etc.) that sends a claim for payment to the government (e.g., Medicare, Medicaid, or other state or federal program)
    •  For services that were not performed; or,
    •  For services that have been up-coded (patient given treatment X, but coded as the more expensive treatment Y).
  •  A healthcare provider that certifies compliance with the law when in fact they are not compliant.
  • For more information, the U.S. Office of Inspector General ("OIG") has produced an easy to understand overview of healthcare fraud for physicians, which outlines a number of example cases and scenarios.

Oklahoma Medicaid Fraud Control Unit

Oklahoma has a Medicaid Fraud Control Unit within the state Attorney General's office.  The director for the Fraud Control Unit works within the AG's office at MFCU Medicaid Fraud Control Unit of Oklahoma Office of the Attorney General 313 N.E. 21st Street Oklahoma City, OK 73105, Tel: 405-521-3921 Fax: 405-522-4875.

Oklahoma has three districts of the U.S. Department of Justice, Western (Oklahoma City), Northern (Tulsa), and Eastern (Muskogee).  As reported by the U.S. DOJ and the Daily Oklahoman (Dec.19, 2010), the following were Oklahoma results:

* The Eastern District collected $2.1 million.
* The Northern District collected $17 million and obtained forfeiture orders of $52 million in criminal and civil cases. So far, $1.1 million has been paid to victims.
* The Western District reported $5.2 million collected.

A listing of all states' Medicaid Fraud Control Units is maintained at the OIG.

What to do if you know of Medicare/Medicaid Fraud

The laws governing fraud against the government are some of the most complex and dense in our legal system and are dealt with within the Federal Judiciary.  Understanding whether you have a claim, what to do about it, and how to get protection from retaliation are matters which should be considered confidentially with an attorney who understands the complex body of law.

Meyer, Leonard & Allison in Oklahoma City has extensive experience in the federal arena and competence in assessing qui tam matters.  To consult in confidence with one of our attorneys, please call 405-702-9900.