It is against the law for a medical provider to fraudulently alter their billing codes under government healthcare programs to induce the government to pay them more money. People who speak out against these fraudulent acts are protected under federal whistleblower statutes. Whistleblower statutes are put in place to encourage people to speak out against fraud and to protect whistleblowers from retaliation. Individuals who blow the whistle on fraudulent billing practices can be compensated handsomely.
In 2014, more than $2 billion was recovered by the government for false claims to federal healthcare programs. Moreover, whistleblowers were compensated substantially for their services, as payments made to whistleblowers improved by $100 million from the previous year.
Walgreen’s has been pursued under the False Claims Act. Walgreens settled a lawsuit for $7.9 million in 2012, after two pharmacists sued it on behalf of the government. However, Walgreen’s did not acknowledge misconduct or liability in that case. It was suspected of luring Medicare and Medicaid patients with gift cards and causing the federal and state governments to pay false claims.
An orthopedic surgeon at a teaching hospital and the hospital’s director of real estate, brought qui tam action under False Claims Act and Illinois Whistleblower Reward and Protection Act. The suit alleged that surgeons double billed Medicare by representing that they were available to perform or oversee surgeries, as required by Teaching Physicians Regulations, when they were in fact performing other surgeries. Goldberg v. Rush University Medical Center, 929 F. Supp. 2d 807 (N.D. Ill. 2013).
In Massachusetts, A former neurosurgeon and assistant professor alleged that her employer had knowledge that she engaged in conduct that reasonably could have led to a False Claims Act action, as required to state a FCA retaliation claim, by alleging her employer submitted excessive or otherwise improper claims to the government and that she notified hospital supervisors of that conduct. Soni v. Boston Medical Center Corp., 683 F. Supp. 2d 74 (D. Mass. 2009).
What are the Requirements Under the False Claims Act?
Medical Providers or any other party dealing with the federal government are forbidden from “knowingly” presenting, or causing to be presented, a false or fraudulent claim for payment or approval to the government or one of its official representatives. See 31 U.S.C.A. § 3729(a)(1)(G). The U. S. Attorney General, or an individual by qui tam (a/k/a Whistle Blower action) may bring a civil action for a violation of the False Claims Act for the person and for the United States Government. 8 Fla. Prac., Constr. Law Manual § 4:5 (2014-2015 ed.) If the Government proceeds with a qui tam action brought by an individual, that individual may receive from 15% to 25% of the proceeds of the action or settlement of the claim, depending upon the extent to which the person substantially contributed to the prosecution of the action. Id.
If the Government decided not to move forward with the qui tam action and the private person proceeds and recovers for the government, the person bringing the action or settling the claim shall receive an amount which the court decides is reasonable for collecting the civil penalty and damages. Id. The amount shall be not less than 25% and not more than 30% of the proceeds of the action or settlement. Id.
Civil liability under the federal False Claims Act needs a showing that a false record or statement was submitted with the intent of the government deciding to pay or approve the false claim. Id. It is inadequate to show simply that the false statement’s use resulted in obtaining or getting payment or approval of a claim. Id. Therefore, an entity must knowingly attempt to deceive.
We understand the nuances of qui tam cases, and are dedicated to helping our clients do the right thing in case of fraud. If you or someone you know is thinking about coming forward with information about false claims, please contact the Dolman Law Group at (727) 451-6900.
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