Ileana Hernandez of Manatt Discusses the Signs of Healthcare Fraud

Ileana Hernandez of Manatt, Phelps & Phillips Law Firm is a member of the firm’s healthcare litigation practice. She has practiced in pharmaceutical and medical device patent enforcement litigation, False Claims Act cases, antitrust laws, class actions, appellate law, and intellectual property disputes.

Hernandez sat down with us to discuss the signs of healthcare fraud and how to best fight it.

In your opinion, what are some common practices used by those trying to commit healthcare fraud?

One of the most prevalent types of healthcare fraud is billing for services not provided or more expensive medical equipment than was actually used. Unfortunately, detecting this type of fraud can be challenging because it requires a medical professional to review the records and look for inconsistencies.

In your opinion, what are the biggest indicators of healthcare fraud?

The billing method is one indicator. Typically those committing health care fraud use a common practice where a provider will bill a patient multiple times for the same service or procedure. This allows them to pad their own pockets and increase profits.

You mentioned the various methods used to commit healthcare fraud, of which billing is one. Are there any others?

One common issue with physician-owned medical facilities is that they might not provide enough services or treatments in their offices to become profitable under Medicare and Medicaid reimbursement rules. This results in providers using other means such as:

Hiring doctors and engaging in leasing arrangements to receive legitimate treatments and services for the doctor’s patients. At the same time, they can unlawfully bill Medicare and Medicaid for physician services.

When you come across a case of healthcare fraud such as these, what do you think is the best way to fight it?

Whistleblowers typically report these cases. If you are aware of any fraudulent activity taking place, you should report it immediately to the Department of Justice.

The False Claims Act rewards those who come forward with information about healthcare fraud committed against the government and allows them to recover funds for their efforts. As a result, whistleblowers play an essential role in major cases, such as the most recent case against GlaxoSmithKline.

In your opinion, what is the biggest issue with healthcare fraud?

The numbers don’t lie – according to a report by the National Health Care Anti-Fraud Association (NHCAA), nearly 10 percent of all health care expenditures in 2010 were fraudulent. The estimated amount of fraud in 2010 was over $30 billion.

The Justice Department recovered about $1.6 billion from False Claims Act cases in the fiscal year 2011, the highest recovery in the act’s history and nearly triple what was recovered in 2009. Whether through civil action or whistleblower lawsuits, healthcare fraud is a serious problem that needs to be addressed.

What advice would you give to the everyday person who wants to fight healthcare fraud?

I would advise that you report it and help develop substantial evidence, such as hard copies of documents from those committing fraud or those allegedly complicit in this type of behavior. Don’t delete any emails or destroy any paperwork! Once they have all the evidence, they will go after them.

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