Necessary Equipment, Unnecessary Fraud: Whistleblowers Can Beat Medicare Scams

10/07/2013 // Whistleblower Law Firm // Keller Grover, LLP // (press release)

It is a Medicare benefit intended to support patients as they cope with, and get treatment for, illness and incapacitation. But it has also become a magnet for fraud. Whistleblowers — those with inside knowledge of improper practices — can help put it to an end.

The Durable Medical Equipment benefit was designed to provide patients with the basic items essential for their care — hospital beds, walkers, wheelchairs, oxygen tanks, and so on — when they are outside a traditional hospital setting. It was based on the recognition that patients are increasingly being cared for at home, but need access to the same basic equipment found in more traditional healthcare settings. Medicare provides the Durable Medical Equipment benefit, or DME, in order to pay for items that are medically necessary, prescribed by physicians or medical professionals authorized by Medicare, and are “capable of repeated use.”

The fraud, it turns out, comes all too easy. The Centers for Medicare & Medicaid Services projects that spending on durable medical equipment nationwide could reach $44.7 billion in 2013. That’s a figure that makes a tempting target for those looking for easy, if wrongfully acquired, money. In many cases, products are provided — and Medicare billed for them — even when they are not medically necessary, resulting in billions of dollars in fraudulent DME claims every year. There are other DME frauds, as well, such as sham medical providers preying on those with legitimate needs for these products.

The fight against DME fraud — like the battles against all types of Medicare and Medicaid fraud — can be greatly assisted with the help of whistleblowers. These are individuals who have inside knowledge of the wrongdoing and can identify how it is happening — and who is behind it. The federal False Claims Act provides them with incentives and support to do just that.

The False Claims Act has proven an extremely powerful weapon in the fight on Medicaid fraud, as well as other frauds against the government,” says Jeffrey F. Keller, a founding partner at Keller Grover, a nationally recognized labor and employment law firm, and a veteran whistleblower lawyer. “Those who speak out and help shut down scams like improper DME billing can receive part of any ultimate recovery the government receives. The statute also supports whistleblowers by giving them rights if they face retaliation by employers. So you can do the right thing for the government knowing you will have rights if you are demoted, fired, or otherwise penalized.”

Since it was substantially amended in the mid-1980s, the False Claims Act has led to the recovery of more than $34 billion in wrongfully paid out government funds.

“Every time a False Claims Act case results in a recovery, it is a win not just for the government and for taxpayers, but for every individual who may have a legitimate need for an important resource — like necessary medical equipment, in the future,” says Keller, whose firm has offices in Los Angeles and San Francisco. “When we recover funds that were wrongfully paid, we can steer that money back to where it belongs: to people in need. In a time of tightened budgets and ever-dwindling funding, that has become especially important. Whistleblowers help ensure that the resources we do have go where they can provide the most help, and do the most good.”

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