How Patients Earn Whistleblower Rewards by Studying Their Explanations of Benefits (EOBs) Most people think whistleblowers have to be company insiders. That is not always the case. We often represent patients who discover overbilling on their Medicare Advantage Plan’s Explanation of Benefits (EOB) forms. By paying attention to those EOBs, patients can help the government uncover massive frauds.
Plus, as whistleblowers, patients can earn rewards worth hundreds of thousands of dollars and, sometimes, even millions of dollars. Take the recent case of two men who submitted more than $3.8 million in false claims to Medicare Advantage and Medicaid managed care plans. The owner and manager of a durable medical equipment supplier in New York billed Medicare Advantage and Medicaid managed care plans for hundreds of expensive patient support systems. These support systems included large devices that were designed to assist with lifting immobile patients and patients in nursing homes. The men, however, did not actually provide the expensive support systems. Instead, they gave patients recliner chairs that had a seat lift feature. Between December 2010 and February 2014, the two men fraudulently billed Medicare Advantage and Medicaid managed care plans more than $3.8 million and were paid approximately $2.4 million. It is almost impossible for the government to discover this type of fraud on its own. Every year, the government processes 1.2 BILLION fee-for-service claims for more than 33.9 million Medicare beneficiaries who receive health care benefits through the Original Medicare program. That is more than 3,000,000 (Three Million) claims every day. And that doesn’t include claims for reimbursement processed by Medicare Advantage, Medicaid, and Medicaid managed care plans. With such a large number of claims being filed every day, the government cannot check every delivery to find out what the patients actually received. That’s where the patients come in. To ensure that patients are actually receiving the products and services that the government is paying for, the government needs patients to review their EOBs. Most people only look at the EOBs to find out how much they have to pay. If the number is small or zero, they don’t bother looking at the details. Fortunately, our clients take the time to look at the details. Over the years, our clients have earned millions of dollars in whistleblower rewards uncovering fraudulent billing for durable medical equipment, dental procedures, hyperbaric oxygen therapy, home healthcare services, urgent care center treatment, pharmaceuticals, and many other healthcare products and services. So, what happened with the two men who fraudulently billed the government for expensive support systems when they were delivering only recliner chairs? They have been convicted and have to pay back all the money they received plus penalties. If you have evidence of false or inflated claims being submitted to your Medicare Advantage plan, you should consult with an experienced whistleblower lawyer right away. You may be entitled to a whistleblower reward of between 15% and 30% of the amount the government recovers. But do not delay. Only the first whistleblower is entitled to a reward. To schedule a free and confidential consultation with an experienced whistleblower lawyer, call us today at (212) 601-2728. John Howley, Esq.
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Pay Careful Attention to Your Explanation of Benefits (EOBs) When we think of whistleblowers, we usually think of corporate insiders who have access to secret documents and records. In healthcare, however, patients are the ultimate insiders.
Patients have a powerful weapon to fight Medicare and Medicaid fraud. It is called their Explanation of Benefits (EOB). EOBs explain what charges were billed to the insurance program, how much was allowed or disallowed, how much was paid to the provider, and how much, if any, the patient must pay themselves. Many patients only look at the last category to see how much, if anything, they must pay. That is exactly how fraudsters like it. Patients who take the time to read their EOBs carefully may be surprised at what they find. Patients often find mistakes, charges for services that were not provided, double billing, and other types of Medicare and Medicaid fraud. We have represented a number of patients who uncovered false claims to Medicare and Medicaid by studying their EOBs. Several have received whistleblower rewards for helping the government uncover improper charges. Some of our clients found that the government was charged for services that were not provided. Others found that the government was charged for an expensive, complicated service, when the patient actually received a basic check-up. Another common fraud that can be caught by reviewing your EOBs is double-billing. In its simplest form, a healthcare provider asks you to make a payment because your service is not covered by Medicare or Medicaid. After you make the payment, however, the EOB shows that Medicare or Medicaid paid the provider again for the same service. If you look only at the bottom line on the EOB – which says that you owe nothing – you might miss the fact that the provider was paid twice for the same service, once by you and again by the government. Obviously, you are entitled to a refund under these circumstances. You may also be entitled to a substantial whistleblower reward if you follow the proper procedures to report the double billing to the government. A claim for reimbursement is considered a “false claim” if the provider was already paid by the patient. When you report a false claim to the government using the False Claims Act, the government will investigate to determine whether this was a mistake or whether the provider is double billing patients on a regular basis. A provider that double bills on a regular basis will be liable for three times the amount they were paid, plus a penalty of up to $11,000 per claim. That can add up to millions of dollars. As a whistleblower, you are entitled to a reward of between 15% and 30% of the amount actually recovered. If you find improper charges on your EOB, you should consult with an experienced whistleblower lawyer immediately to protect your rights. There are strict procedural requirements and time limits to qualify for a whistleblower reward. To schedule a free and confidential consultation with a whistleblower lawyer, call John Howley, Esq. at (212) 601-2728. |