The Federal False Claims Act provides that whistleblowers who disclose fraud have the right to be rewarded for making valid disclosures. The whistleblower files his/her claim through the qui tam provisions of the False Claims Act. Whistleblowers should work with experienced qui tam attorneys who can advise the client about when and how to make the disclosure and what types of disclosures can lead to a percentage of the recovery.
The False Claims Act authorizes litigation against any entity that does business with the federal government and then submits false claims to the government. Tax fraud and other types of fraud are covered by different laws. Many False Claims Act cases involve whistleblowers who disclose various types of health care fraud. Pharmaceutical fraud is one such health care practice area where fraudulent claims are filed with Medicare and Medicaid.
Sometimes, entities that file false claims are also in violation of the Anti-Kickback Statute and other federal laws.
Types of pharmaceutical fraud
In pharmaceutical fraud cases, whistleblowers include compliance officers, physicians, sales representatives, nurses, medical practice employees, and others. Some common types of fraud or false billing practices that can lead to a whistleblower/False Claim Act case include:
- Overbilling or inflating the price for medications and drugs that were supplied. Often Medicare and Medicaid preset the amount they will pay for drugs based on the Average Wholesale Price or the Best Price. Manufacturers of drugs who engage in schemes to obtain more from Medicare than authorized or to provide incentives to doctors to prescribe the manufacturer’s drugs over other drugs may violate the False Claims Act.
- Off-label marketing. Generally, drugs must be approved by the Food and Drug Administration (FDA). The drugs are usually approved for just certain types of treatments. Doctors may be able to approve some drugs for certain conditions without FDA approval. While doctors can prescribe these drugs, pharmaceutical companies can’t market or suggest that doctors prescribe the company’s non-approve (off-label) drugs.
- Kickbacks that are illegal. In conjunction with Anti-Kickback Law, pharmaceutical companies may violate the False Claims Act if they offer incentives to physicians to get the physician to prescribe the company’s drugs. Illegal kickbacks include cash payments, vacations, expensive dinners, gifts, and other benefits – including free samples of the drugs which the doctors may sell to patients.
- Charging for medications that weren’t necessary
- Only partially filling the prescription instead of providing the full prescription
- Providing drugs that the company knows won’t work for the patient’s condition
- Improper upcoding
- Changing prescriptions for illegitimate reasons
- Improper PBM management. Companies called “pharmaceutical benefits managers (PBMs) are hired to help insurance companies manage the cost of available drugs – such as by negotiating price adjustments with pharmaceutical companies. The PBMs, drug manufacturers, and insurers must act honestly so the patient gets the best price and the taxpayer isn’t overbilled.
If you are aware of any type of fraud including any kind of pharmaceutical fraud, the experienced whistleblower lawyers at Stephen Danz & Associates are ready to help. We are respected across California for our ability to pursue whistleblower claims. For help now, call us at 877-789-9707 to schedule an appointment.