Dr. Darren Sewell worked as a physician and health care director for Freedom Health, a Tampa-based HMO, from 2007 to 2012, and two years into his tenure at the HMO, he worked with an attorney to file a federal lawsuit against Freedom Health based on widespread Medicare fraud perpetrated by the company. The company was not aware of Dr. Sewell’s lawsuit, but the Department of Justice was impressed by the allegations contained in the suit and asked Sewell to work as an undercover informant to gather further information relating to Medicare fraud. Dr. Sewell courageously did so, and although he passed away in September 2014, his estate now stands to receive between $4.8 and $8.1 million as a whistleblowing reward for his valiant efforts which led to a $31.7 million settlement with Freedom Health and Optimum HealthCare, where Dr. Sewell also served as a director.
Dr. Sewell’s Allegations of Medicare Fraud and Misrepresentations
Dr. Sewell’s allegations against the two companies were based on their ongoing abuse of the Medicare Advantage program which sets reimbursement rates based on a payment formula called a “risk score.” Through the program, patients in Medicare plans are given risk scores correlating with their level of health, and organizations can charge higher reimbursement rates for patients with higher risk scores. Dr. Sewell’s complaint alleged that his employers engaged in widespread fraud to increase risk scores by lying about its patients’ health conditions and claiming to provide services that were never actually provided. Although the companies continue to deny culpability, they will pay $16.7 million to settle the claims that they fraudulently adjusted risk scores.
In addition, Dr. Sewell presented information to the federal government that Freedom Health lied about its size and resources in an attempt to get government approval to extend into other territories, while in actuality being unable to provide sufficient medical resources to its patients. The health care provider will pay $15 million to settle these claims.
An Example for Would-be Medicare Whistleblowers
Dr. Sewell clearly acted courageously in not only pursuing a confidential FCA whistleblower suit against his employers but also in working undercover on behalf of the federal government. And the 8-year progression from when he filed his suit and when his family recovered (his family pursued the case after his death) is a sign of the commitment whistleblowers suits can require. But Dr. Sewell’s family can remember his legacy as an individual who stood up for patients and taxpayers, while also earning a multi-million dollar whistleblower reward for his estate.
At Kreindler & Associates, we understand that the decision to become a whistleblower is not an easy one. The government relies on courageous insiders like you to come forward with information that can stop harmful Medicare fraud. Our experienced healthcare fraud attorneys will work with you every step of the way to determine your appropriate course of action, protect you from retaliation, and collect your much-deserved reward. If you suspect that someone is committing Medicare fraud, contact us today for an evaluation of your allegations.