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Allegations of $4.8 million to Humana due to billing fraud scheme

A lawsuit filed by a South Florida doctor was recently unsealed. The filing alleges that Humana, a huge insurance company, knew that a doctor in Delray Beach cheated the U.S. government out of $4.8 million through a Medicare billing fraud scheme.

The Center for Public Integrity released a report last week saying that Humana didn't do much to stop the billing scheme, even though it potentially could have harmed patients. The lawsuit alleges that the scheme was carried out for seven years. Humana apparently got 20 percent of the money from Medicare. The other 80 percent went to the Delray Beach doctor.

According to prosecutors, the $4.8 million overpayments occurred between January 2006 and June 2013. Last year, the Delray Beach physician was indicted on charges of health care fraud. He has since indicated that he would likely plead guilty. The health care fraud charges are due to fraudulent diagnoses that resulted in the overpayments.

Humana hasn't commented on the whistleblower lawsuit. The basis for the whistleblower lawsuit is a billing formula that pays more for sicker patients. This is called a risk score. Humana currently covers over 3 million Medicare Advantage patients across the country.

When someone had knowledge of an attempt to defraud the federal government, a whistleblower lawsuit may be filed. If the lawsuit is successful, then the whistleblower can end up with a percentage of the money that was taken illegally. Whistleblowers are protected from retaliation from their employers. If you believe you have information about corporate wrongdoing, such as billing Medicare for treatments that were not medically necessary, you should speak with an experienced whistleblower attorney to learn about your legal options.

Source:, "Indicted Delray Beach doctor is focus of $4.8M whistleblower lawsuit," John Pacenti, March 08, 2016

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