Types of Health Care Fraud

Types of Health Care Fraud | Heath Hyde

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Health care fraud that can be reported under the whistleblower provisions of the False Claims Act (Qui Tam) can involve many types of wrongdoing. Whistleblowers are often the catalyst in attracting Federal Prosecutors to investigate health care fraud. Whistleblowers are motivated by the rewards they may qualify for if they feel they may have witnessed various kinds of health care fraud.

Health care fraud in the United States collectively results in billions of dollars of false claims paid by the government each year. There are both State and Federal false claims Acts that provide whistleblowers the right to file suit as well as the Dodd-Frank whistleblower Act. Cases brought under the federal and state false claims act and under Dodd-Frank whistleblower programs of the SEC and CFTC provide financial rewards to private citizens who properly report wrongdoing to the government.

Heath Hyde Defends Defendants in Whistleblower Claims

The law firm you choose can make all the difference. More than 90% of False Claims Act cases are unsuccessful. Less than 1% of SEC and CFTC whistleblower complaints result in an award—in fact, less than 3% of whistleblower complaints cause the SEC or CFTC to even open an investigation. We build successful cases with our whistleblower accused clients that take full advantage of those odds.

Most defendants in high-stakes False Claims Act litigation retain large, powerful If you believe your are soon to be a defendant or have already been named in a false claims suit it is very important you immediately obtain experienced and capable federal legal counsel. As you might imagine, False Claims Act whistleblower law firms that successfully litigate cases against defendants represented by quality defense firms in high-stakes litigation think twice about investing significant capital in a false claims suit.

Most whistleblower law firms do not do this but merely prey upon those who do not understand the complex process of this kind of litigation. Choosing a Federal Criminal Defense firm with experience and talent can make the difference if you are a defendant in a False Claims Act case.

Heath Hyde represents defendants under the SEC and CFTC whistleblower programs. Our clients mount successful defenses under the SEC and CFTC whistleblower programs. We take a small number of cases—often avoiding enforcement investigations altogether.

Before you make a decision about which law firm and which lawyers you trust to best represent your interests when accused by a whistleblower, contact our federal  false claim act law experts and learn what makes Heath Hyde Lawyer special and the most talented and experienced to protect your rights and freedoms.

Types of Health Care Fraud

Types of health care fraud include:

  • Overbilling or incorrect billing for services. This can include up-coding, unbundling, or other duplicative billing schemes.
  • Off-label promotion and marketing of drugs and medical devices.
  • Billing for services not provided or services that were not medically necessary, including prescribing unnecessary medications.
  • Fraudulent risk-adjustment data supplied to health care.
  • Acceptance or offering of kickbacks or bribes of any kind, including illegal referrals, in violation of the Anti-Kickback Statute and Stark Law.
  • False pricing and cost reports, including false certifications.
  • Falsifying claims or diagnoses.
  • Reimbursement when a beneficiary is not eligible for reimbursement.
  • Billing for “ghost patients,” or claims made for a patient that either does not exist or who never received the service or item billed for.
  • Retention of overpayments.
  • Hospital and other medical provider fraud. Hospitals, hospice centers, outpatient facilities and other health care providers are required to submit cost reports and other documents in order to be eligible for receipt of Medicare/Medicaid funds. Falsification of those documents and false statements in support of these submitted materials often provide the basis for False Claim Act liability.

Below are examples of some of the most impactful whistleblower cases so you can gain a feel for how these cases develop and settle:

What are the Forms of Healthcare Fraud? 3 | Heath Hyde

False Claims Act (qui tam)

Countrywide Financial (Mortgage / Appraisal Fraud)

A Countrywide and Bank of America whistleblower challenging widespread mortgage fraud through fraudulent appraisal and underwriting activity committed by Countrywide Financial Corp. (and later Bank of America) in U.S. ex rel. Lagow v. Countrywide Finan. Corp. (E.D.N.Y.) resulting in more than $1 billion-dollar settlement. This case began a new era of mortgage fraud enforcement that continues to this day.

Bank of America Corp. (Mortgage / Servicing Fraud)

A  Bank of America whistleblower challenged Bank of America’s failure to provide benefits to homeowners under the Home Affordable Mortgage Program in U.S. ex rel. Mackler v. Bank of Amer. Corp. (E.D.N.Y.) earning a large award from the same billion-dollar settlement. This case commenced a wave of litigation on behalf of homeowners wrongly denied mortgage relief by banking giants

Amgen (Health Care / Pharmaceutical Fraud)

A physician and research scientist filed suit challenging unlawful conduct by pharmaceutical giant Amgen Inc. in the health care fraud case U.S. ex rel. Horowitz v. Amgen Inc. (W.D. Wa.) This case drew attention to several unlawful pharmaceutical industry practices, including relationships with medical providers and drug industry brokers.

US WorldMeds (Health Care / Off-Label & Anti-Kickback Statute)

A Senior Medical Director at US WorldMeds  settled a False Claims lawsuit, U.S. ex rel. Dr. v. US WorldMeds LLC (W.D. Wa. / D. Conn.), challenging the company’s off-label promotion and unlawful kickbacks to medical providers for use of its injectable products. This case settled in 2019, highlighting the improper relationships between pharmaceutical/medical device/drug manufacturers and medical providers who agree to use their products and the critical importance of enforcing the requirements of the Anti-Kickback Statute through the False Claims Act. 

Medtronic (Health Care / Medical Device Fraud)

A nationally ranked sales representative and a medical device engineer alleged fraud in this settled lawsuit, U.S. ex rel. Nowak v. Medtronic Inc. (D. Mass.), challenging Medtronic’s off-label promotion of medical devices. This important case, which was settled, highlighted an industry practice of off-label marketing and promotion of medical devices approved by the FDA as one class of device, though promoted for higher-risk use.

Pfizer (Health Care / Pharmaceutical Fraud)

We represented an expert physician and scientist in the False Claims Act suit, U.S. ex rel. Polansky v. Pfizer, Inc. (E.D.N.Y.) challenging the company’s alleged off-label promotion and marketing of the blockbuster statin drug Lipitor, at one time the most profitable drug in America.

A Health care finance expert Anthony Kite filed a complex lawsuit, False Claims Act litigation, U.S. ex rel. Kite v. Besler Consult., et al. (D. N.J.), against several large hospitals who committed Medicare fraud through false claims for “outlier” payments. Mr. Kite’s diligent efforts resulted in a multimillion-dollar award to him but the defendants avoided criminal investigation and prosecution.

Center for Diagnostic Imaging (Health Care / Provider Billing Fraud)

A physician and health care executive whistleblower tandem, challenged Center for Diagnostic Imaging, Inc.’s violation of anti-kickback laws through its presentment of false claims to the government in U.S. ex rel. West v. Center for Diagnostic Imaging, Inc. (W.D. Wa.). In this complex case, the whistleblowers recovered additional funds for the government and personal awards but the defendant was not investigated and avoided criminal prosecution.

Sound Inpatient Physicians (Health Care / Provider Billing Fraud)

A former regional vice president of Sound Physicians in this health care fraud case challenging widespread “upcoding” in support of health care fraud in U.S. ex rel. Thomas v. Sound Inpatient Physicians, Inc. (W.D. Wa.). This case resulted in a large settlement and awardto the whistleblower but no formal investigation or criminal prosecution.  

Dodd-Frank Whistleblower SEC/CFTC Cases

There are Dozens of whistleblower cases in confidential cases and settled cases that are never disclosed; cases identified only with client permission.


A whistleblower sparked the successful investigation and prosecution of this “hi-tech scam” investment fraud case that was resolved by the SEC 2020. The violations of federal securities laws are set forth in the SEC’s complaint. No criminal charges were levied against the defendants.

BATS / Direct Edge Stock Exchanges (SEC Whistleblower Case)

In one of the first successful SEC whistleblower cases, a whistleblower Haim Bodek, a leading algorithmic trading expert, in his complaint against BATS Global Inc. / Direct Edge Holdings challenged the unlawful preferential treatment it gave certain preferred high-frequency trading companies. This case resulted, in 2015, in the largest SEC fine ever imposed on a U.S. financial exchange. Mr. Bodek’s work was twice reported on the front page of The Wall Street Journal and he was rewarded for his work. Fortunately, even with extensive publicity the defendants avoided criminal prosecution.


A whistleblower behind the 2018 SEC action against the New York Stock Exchange (NYSE) which resulted in a record-tying fine against the large financial exchange. The defendant avoided investigation and criminal prosecution. See SEC Order

Navinder Sarao / Nav Sarao Futures Ltd. (CFTC Whistleblower Case)

In the most prominent CFTC whistleblower action since the program began, an anonymous whistleblower identified, through expert, proprietary analysis, a previously undetected cause of the 2011 market “Flash Crash,” resulting in the first ever Department of Justice prosecution and guilty plea following extradition of a foreign market manipulator. The defendant avoided incarceration by accepting negotaiated extradition. See DOJ release

Cargill Inc. (CFTC Whistleblower Case)

A whistleblower is responsible for the CFTC’s action against the largest privately held corporation in the United States, which agreed to pay an eight-figure civil penalty from the CFTC for providing inaccurate information on swaps and failures to supervise. The defendant avoided criminal investigation and criminal prosecution. See CFTC release.

Contact Heath Hyde Today for Health Care Fraud Defense

Heath Hyde is one of the top federal lawyers in the United States helping clients avoid investigation and prosecution in health care fraud allegations lodged by whistleblowers (Qui Tam). Contact Heath Hyde at 903.439.0000 for a confidential case evaluation or submit your case via our website.

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