Medical Loss Ratio Fraud and Whistleblower Cases

Whistleblowers are essential for stopping medical loss ratio (MLR) fraud. They can do this by filing a "qui tam" (whistleblower) lawsuit.

MLR fraud takes many forms, but usually involves reporting false information to the government, such as information about profits or medical costs.

A whistleblower lawyer can confidentially evaluate your case at no charge, then discuss possible government rewards and ways to protect your job.

Medicare and Medicaid have turned increasingly to private companies to offer benefits through Medicare Advantage Plans, Medicare Part D Plans, and Medicaid Managed Care Plans. To ensure that most of the money that Medicare and Medicaid pay these Plans is spent on services-rather than pocketed as administrative expenses or overhead-Medicare and Medicaid require many Plans to maintain a minimum Medical Loss Ratio (MLR).

Because reporting MLR often means returning money to the government, plans may resort to fraud to avoid their legal obligations. Medical loss ratio fraud can be hard for regulators to detect, which is why whistleblowers - whether inside or outside the company - are needed to help stop the fraud.

If you know of a Medicare Advantage plan or a Medicaid Advantage plan violating federal or state medical loss ratio rules, you may want to contact a whistleblower attorney. Phillips & Cohen offers free and confidential consultations to individuals who are considering filing a whistleblower case. The law firm has substantial experience representing whistleblowers in medical loss ratio fraud cases and can evaluate how whistleblower laws apply in your case and explain the rewards and job protections that whistleblowers are offered through the False Claims Act.

Though medical loss ratio fraud can take many forms, here are some common ways it can occur:

  • Paying provider claims that should have been denied under Medicare rules.
  • Making excessive or duplicate payments to providers.
  • Reporting false information, such as profits or medical costs, to the government in order to make the MLR look higher than it really is.
  • Hiding or misallocating revenue from one contract to the next.
  • Falsely classifying administrative expenses as claims-related expenses.

An example of a successful whistleblower lawsuit that involved alleged manipulation of medical loss ratios was the case against WellCare Health Plans, a Florida-based managed healthcare provider. The lawsuit alleged WellCare falsely inflated how much it was spending on medical care to avoid paying a rebate to Medicaid and other programs.

Ultimately, WellCare agreed to pay $137.5 million to the federal government and nine states to resolve the claims. The whistleblowers received more than $25 million for their role in the recovery.

Keep in mind that timing is important in a whistleblower case. Contact Phillips & Cohen for more information.

(Read more about choosing a whistleblower lawyer.)