The Medicare litigation process is a little like the game show Deal or No Deal. One contestant is selected and asked to say a phrase, “I think I might win” or “I’m thinking maybe I could” and then they have to give the reason why they are so sure. Sometimes the reason is quite clear, other times it’s not so easy to determine why a claimant is certain that they will win the case, even when there are multiple reasonable possibilities. When this happens, Medicare defendants’ lawyers are called upon to make an honest assessment of the situation and decide how to proceed with the original claim or refiling.
The Medicare claims process was enacted to protect the government’s interest in settling benefits for the wrongfully awarded Medicare benefits to innocent individuals who were awarded but didn’t deserve them.
Although Congress passed the Medicare Claims Act with broad legislative language regarding qui tam lawsuits, the Act itself is rather ambiguous when it comes to the process itself. In addition, judges have cited a number of possible abuses of the process, including double billing and fraudulent billing practices and medical device manufacturers’ violations of patient Medicare benefits. Many of these obvious abuses take place on a day-to-day basis without being noticed by the senior management at companies that provide the services that are the subject of these lawsuits.
What can you do if you are a victim of Medicare or Medicaid fraud?
You need to know your rights under the Medicare claims act, and you need to take action fast. If you are not sure what kind of protections are present, you should contact a qualified Medicare attorney who specializes in this area. It is important that you retain only a Medicare lawsuit lawyer who has a good reputation and is experienced in dealing with these kinds of cases. In fact, you would be wise to seek legal counsel from an attorney who handles such cases on a regular basis.
Whistleblowers who are subject to this kind of attack from providers may have other options available to them, such as communicating with the U.S.
Department of Health and Human Services’ Centers for Medicare and Medicaid Services (CMS) Medicare claims adjudication process office. The claims adjudication process is not meant to be an adversarial relationship. Instead, it is meant to ensure that the process works as intended. While the CMS may not have the power to reduce or eliminate your benefits, the agency can certainly provide assistance to you in various forms.
For example, you may have legitimate issues that must be considered when deciding whether to pursue the matter through the appeals process.
You may also need help to determine which laws apply to your situation, such as those related to mandatory arbitration clauses. An experienced Medicare litigation attorney will have a strong resource list and knowledge of all the rules and regulations pertaining to your specific situation. He or she will also be familiar with various forums where you can pursue your claims. These forums could include medical groups, consumer advocate groups, or independent organizations.
Perhaps best of all, a credible Medicare litigation attorney will have contacts to various providers within the system who can provide you with support during the appeals process.
Because providers are familiar with the rules, they may be willing to work with you rather than let the case drag on. You might also find that providers are receptive to allowing you to participate in the appeals process alongside them, provided that you are able to cooperate. This type of assistance could prove very helpful, particularly if you have an extremely large case.