Monday, January 21, 2013

Pharmacy Whistleblower Recoveries: State and Federal Medicaid Fraud Laws Offer Large Rewards To Pharmacy Whistleblowers by Pharmacy Whistleblower Lawyer

Pharmacy Whistleblower Recoveries: State and Federal Medicaid Fraud Laws Are Offering Large Financial Rewards To Pharmacy Whistleblowers That Expose Drug Company Marketing Fraud by Pharmacy Whistleblower Lawyer Jason S. Coomer

State Attorney General Offices are targeting drug companies and retail pharmacy chains that seek to manipulate drug prices to their advantage.  These drug price Medicaid fraud whistleblower lawsuits include pharmacy chains that fail to perform a required drug utilization review and attempt to defraud government health care programs.  Many of these State Attorney General Offices are working with drug price fraud whistleblower Ven-A-Care.  This pharmacy drug price fraud whistleblower has been working on drug fraud cases since 1994 and has help state and federal governments recover more than $2 billion and has won roughly $380 million for itself in the process. 

On February 1, 2011, a Travis County, Texas jury found that a global pharmaceutical manufacturer had misrepresented drug prices to the state's Medicaid program and said the drug company should pay the state and federal government $170.3 million.  These Drug Price Medicaid Fraud Lawsuits are becoming more common as evidence is coming to light that the $700 Billion a year drug industry includes some large drug companies that are defrauding Medicaid, Medicare, the VA, Tricare, and other governmental benefit programs out of vasts amounts of money.

Several governmental officials have made it clear that those who defraud the Medicaid program, Medicare, the VA, Tricare, CHIP and other government benefit programs will be held accountable for their actions.  Recent changes in the False Claims Act and other Qui Tam laws have created stronger protections and economic incentives for whistleblowers with knowledge of drug price fraud and other forms of Medicare Fraud and Medicaid Fraud.  As such, it is important for drug price fraud whistleblowers, pharmaceutical representative whistleblowers, medical device sales representative whistleblowers, drug marketing representative whistleblowers, and other drug executive whistleblowers to blow the whistle on drug fraud pricing schemes.

Medicaid Drug Marketing Fraud Whistleblower Lawyers, Medicaid Drug Formulary Fraud Whistleblower Lawyers, Targeted Medicaid Off Label Marketing Fraud Whistleblower Lawyers, Medicaid Formulary Drug Fraud Whistleblower Lawyers, & Medicaid Drug Illegal Kickback Marketing Fraud Whistleblower Lawyers

For more on this topic, please go to the following webpages: Pharmacy Drug Price Fraud Whistleblower Lawsuit Information and Medicaid Drug Marketing Fraud Whistleblower Lawsuit Information.
Texas Getting $36 Million in Medicaid Fraud Settlement | The Texas Tribune

"Under the settlement agreements, Texas will receive $18.17 million from Endo Pharmaceuticals and Pfizer Inc. each and additional compensation to cover the state's legal costs. The federal government, which jointly funds Medicaid with the state, will receive some of the money."

"Ven-A-Care, the Florida-based pharmacy that reported the companies to the state, will also receive a portion of the settlement for helping recover the funds. Since 2000, the pharmacy has earned millions by participating in more than 20 Medicaid and Medicare fraud cases in various states, including Texas. According to a Los Angeles Times article from 2011, the company and its lawyers had earned more than $380 million by participating in fraud cases at that time."

"“Both in recoveries for themselves and for taxpayers, Ven-A-Care’s partners are apparently the most successful whistle-blowers in U.S. history,” the newspaper reported."

"In 2011, Texas won a $170 million court case against Actavis, an Iceland-based pharmaceutical company, with the help of Ven-A-Care, which had reported the company to the state for inflating drug prices."

"Under Texas law, whistleblowers can receive 15 percent to 25 percent of the financial penalties of a Medicaid fraud settlement for bringing the case forward. Texas has recovered at least $354 million in Medicaid fraud settlements from pharmaceutical companies — more than any other state — since 1991 with the help of private whistleblowers, according to a report released in September by Public Citizen, a nonpartisan consumer advocacy organization."

The Federal Government and Several States Including Texas Are Making Large Recoveries Through Medicaid Drug Marketing Fraud Whistleblower Lawsuits and Medicaid Drug Price Fraud Whistleblower Lawsuits

In January 2012, the State of Texas and a Medicaid drug marketing fraud  whistleblower squared off against Johnson and Johnson, Inc. and several related companies in Travis County District Court.  In the case, the State of Texas alleged that the large drug company systematically targeted the Texas Medicaid System and fraudulently misrepresented their drug, Risperdal, with false and misleading marketing information.  Further, that the defendants intentionally targeted opinion leaders in the medical community with financial incentives and misleading information in an effort to have the drug placed into treatment guidelines, model state treatment programs, formularies, Texas Vendor Drug Programs, and the Texas Medicaid preferred drug lists.

Attorneys for the State of Texas and Medicaid Marketing Fraud Whistleblower argued that they had reviewed millions of documents and could prove that the large drug company intentionally pushed Risperdal as a safer alternative to the typical medications despite rulings from the Food and Drug Administration that these assertions were not supported by scientific research.  Further, that the defendants orchestrated a fraudulent marketing scheme to seed medical literature with misleading information and influence key medical decision makers to increase Risperdal in the Texas Medicaid Program as well as used this information to push their drug as the established treatment in state Medicaid programs throughout the United States as well as in the Federal Medicare program.

As a result of this Texas lawsuit, the drug maker, Johnson and Johnson, Inc., agreed to settle the Texas Medicaid fraud case for $158 million.  Johnson and Johnson, Inc. has also agreed to a settlement where the drug company will will pay more than $1 billion in civil and criminal penalties to the federal government and individual states to settle an investigation into the marketing practices of its anti-psychotic drug Risperdal.  Johnson and Johnson, Inc. has also been hit in Medicaid fraud cases in South Carolina and Louisiana and was ordered to pay more than $250 million each.

State and Federal Medicaid Fraud Whistleblower Reward Laws Are Expanding

Medicaid is a federal/state cost-sharing program that provides health care to people who are unable to pay for such care.  The Medicaid Program is jointly funded by state and federal governments, but is managed by the states.  Medicaid is the largest source of funding for medical and health-related services for people with limited income in the United States and the Medicaid program has been increasing.  The fastest growing aspect of Medicaid is nursing home coverage and this is expected to continue as the Baby Boomer generation begins to reach nursing home age. 

Unlike Medicare, which is solely a federal program, Medicaid is a joint federal-state program. Each state operates its own Medicaid system.  Each state's Medicaid Program must conform to federal guidelines in order for the state to receive matching funds and grants.  For many states Medicaid has become a major budget issue as on average the state's matching costs of the Medicaid program is about 16.8% of state general funds. According to CMS, the Medicaid program provided health care services to more than 46.0 million people in 2001. In 2008, Medicaid provided health coverage and services to approximately 49 million low-income children, pregnant women, elderly persons, and disabled individuals. Federal Medicaid outlays were estimated to be $204 billion in 2008.  Medicaid payments currently assist nearly 60 percent of all nursing home residents and about 37 percent of all childbirths in the United States. The Federal Government pays on average 57 percent of Medicaid expenses.

Medicaid fraud is a violation of federal law and several new state Medicaid fraud laws.  Health care providers that are convicted of Medicaid fraud can be fined, incarcerated, and lose their status as Medicaid providers.  To prevent Medicaid fraud, several states including Texas, California, Florida, Hawaii, Massachusetts, Nevada, Tennessee, Wisconsin, New Jersey, Georgia, Michigan, Illinois, Louisiana, Delaware, Indiana, Minnesota, Montana, New Mexico, Oklahoma, North Carolina, and Virginia have enacted state Medicaid fraud whistleblower recovery laws.  These Medicaid fraud whistleblower laws are based on the Federal False Claims Act and many acts of large scale systematic Medicaid fraud will entail aspects of several different laws.    

There are many types of Medicaid fraud that may be the basis for Medicaid fraud whistleblower recovery lawsuits and other qui tam claims including:
  • billing Medicaid for X-rays, blood tests and other procedures that were never performed
  • falsifying a patient’s diagnosis to justify unnecessary tests;
  • giving a patient a generic drug and billing for the name-brand version of the medication;
  • giving a recipient a motorized scooter and billing for an electric wheelchair, which can cost three times more;
  • billing Medicaid for care not given;
  • billing Medicaid for patients who have died or who are no longer eligible for Medicaid;
  • billing Medicaid for care given to patients who have transferred to another facility;
  • transporting Medicaid patients by ambulance when it is not medically necessary;
  • requiring vendors to “kick back” part of the money they receive for rendering services to Medicaid patients (kickbacks may also include vacations, merchandise, etc.);
  • billing patients for services already paid for by Medicaid;
  • billing Medicaid for phantom patients;
  • double billing Medicaid for services;
  • upcoding services for increased Medicaid payments.
Upcoding occurs when a medical service provider intentionally and fraudulently upcodes services to obtain a higher reimbursement than one that is entitled to for the service that was actually provided.  In both the Medicare and Medicaid systems a set of billing codes is used by healthcare providers to bill for services. These codes are known as the Healthcare Common Procedure Coding System (HCPCS). A service provider that intentionally uses a higher paying code to fraudulently reflect that a more expensive procedure or device was involved in the patient’s treatment than actually was used or was necessary.  A pattern of intentional upcoding treatment can result in large profits for the healthcare provider, but also cost taxpayers millions of dollars.

Upcoding fraud is typically hard to catch without the help of persons with inside information because that Healthcare Common Procedure Coding System (HCPCS) codes are billed electronically and can easily slip through the system.  Therefore unless the upcoding is caught through a random audit (approximately 2% of the claims per year are audited), it is up to insiders, informants, heroes, and health care professionals to catch fraudulent upcoding.

Another type of coding fraud is “unbundling”, where bundled related procedures or composite lab tests are run together, but billed separately by the lab or healthcare provider to obtain more compensation.  These types of billing fraud also allow healthcare providers and labs to make higher profits by bilking Medicare, Medicaid, and taxpayers out of millions of dollars.  These unbundling fraud schemes are also hard to detect without someone that is familiar with the codes and billing.

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