Health Care Recovery Litigation
Keeping health insurance affordable for all Americans
Americans spend over $3 trillion a year – over $10,000 per person – on health care, and over 34% of that is paid for by private insurance companies.[1] The National Health Care Anti-Fraud Association (NHCAA) estimates that 3% of all healthcare spending – tens of billions of dollars annually – is lost to health care fraud. Whether you have employer/union-sponsored health insurance or you purchase your own insurance policy, health care fraud inevitably translates into higher premiums and out-of-pocket expenses for consumers and employers as well as reduced benefits or coverage. Private health plans have a vested interest in keeping their services affordable and competitive.
Since the majority of health care providers, laboratories, drug and medical device manufacturers serve both publicly and privately insured participants, fraud schemes frequently target both types of insurance. Medicare, Medicaid and the Veterans Administration have fraud protections built in by federal regulation and can incentivize whistleblowers through the federal and state False Claims Acts. Private health insurers, on the other hand, must pursue their fraud recovery claims through a more complex patchwork of state and federal laws.
Our Understanding
Key to being able to support health plans effectively in recovery litigation is a thorough understanding of the managed care business, from pharmacy benefit (PBM) contracting, drug formulary development and claims management to compliance with federal laws such as HIPAA, ERISA and the Affordable Care Act, as well as state health insurance and consumer protection laws.
Our Attorneys
Our attorneys bring more than 60 years of combined experience investigating health care fraud and abuse for third-party payors.
Our Expertise
Baron & Budd leverages its extensive experience in managed care as well as in class action, antitrust, RICO, False Claims Act and state consumer protection litigation to the benefit of its third-party payor clients in health care fraud recovery litigation. We advise clients on how to minimize the potential for fraud in contracting with pharmacy benefit managers, pharmacy chains, specialty pharmacies, laboratories and provider networks as well as assisting clients in auditing performance under these contracts. Our team also assists managed care plans in evaluating the feasibility of bringing follow-on actions to successful Medicare and Medicaid fraud cases; initiating, joining or opting out of class action litigation; assessing potential recoveries under the California Insurance Fraud Protection Act, the Illinois Insurance Claims Fraud Prevention Act and state consumer protection statutes; as well as responding to third-party subpoenas.
[1] https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html