As telemedicine fraud remains a top enforcement priority of the U.S. Department of Justice, whistleblowers can play a key role in helping the government recoup taxpayer dollars lost to fraud.

In September 2021, the DOJ announced charges against more than 43 individuals in 11 judicial districts. The government alleged those individuals took part in schemes involving telemedicine leading to more than $1.1 billion in allegedly false and fraudulent claims being submitted to Medicare and other government insurers. 

The criminal defendants include telemedicine executives who allegedly paid doctors and nurse practitioners to order unnecessary durable medical equipment, genetic and other diagnostic testing, and pain medications, either without any patient interaction or only a brief telephone conversation with patients they had not previously met or seen. 

As part of the scheme, durable medical equipment companies, genetic testing labs and pharmacies purchased the orders in exchange for illegal kickbacks and bribes and submitted over $1.1 billion in false and fraudulent claims.

According to the DOJ, medical professionals in some cases billed for telehealth consultations that did not occur as they’d represented.  

The enforcement action comes on the heels of a 2019 telemedicine takedown which resulted in an estimated cost avoidance of more than $1.9 billion in the amount paid by Medicare for orthotic braces.

In the early days of the COVID-19 pandemic, the Centers for Medicare and Medicaid Services relaxed its rules so that Medicare and Medicaid patients could more easily receive care through telehealth services. 

As a result, use of telehealth jumped: according to the U.S. Department of Health & Human Services, nearly half of all Medicare primary care visits in April 2020 were provided by telehealth, as compared to less than one percent in February 2020. 

With the increase of the use of telemedicine overall during the COVID-19 pandemic, it’s likely that the DOJ will continue to have its hands full of cases, both criminal and civil. 

In a 2021 newsletter, the White Collar Crime Committee of the American Bar Association’s Criminal Justice Section identified common telemedicine fraud schemes. They include healthcare providers upcoding their billings by billing for more time than the provider actually spent talking to patients and documenting diagnoses more severe and complex than the patients’ actual conditions in order to bill at a higher rate, inaccurately reporting the service provided virtually, billing for services not provided and engaging in kickbacks.

On the civil enforcement side, whistleblowers can play a key role in helping the government pursue cases against those defrauding the government. The False Claims Act offers individuals with knowledge of fraud against the government an opportunity to report it to the government. The Act goes back to the Civil War and is one of the government’s most effective tools in fighting fraud. 

The Act incentivizes whistleblowers, or Relators as they are known, to report such fraud by rewarding them with a percentage of the amount the government successfully recovers as a result of the whistleblower’s False Claims Act case. The Act also provides for protections for whistleblowers who do report fraud.

With over 30 years of experience litigating fraud and employment cases, Keller Grover is uniquely positioned to represent whistleblower clients. The firm has recovered billions for its clients. 

If you want to report wrongdoing, we are here to help. For advice about how to handle suspected fraud, contact Keller Grover for a free and confidential consultation.