Scroll Top
Bothwell Law Group 304 Macy Dr, Roswell, GA 30076

What Happens in Medicare Qui Tam Cases?

Learn more about the process for Medicare qui tam cases.

Private individuals use Medicare qui tam cases to show that a person or group has committed fraud against the government. The term “qui tam” is from a Latin phrase. It refers to someone who pursues legal action on behalf of the government as well as themselves. It originated in 13th century England, where it has since fallen into disuse. However, the United States still uses qui tam writs under the False Claims Act and a few other more specific laws. Cases of fraud against the government are the most common types of qui tam cases, especially in Medicare and defense contracting.

Qui Tam Overview

A private individual files a qui tam lawsuit on behalf of the federal government, usually under the False Claims Act. This individual, also known as a relator, is the plaintiff in a qui tam suit. People often refer to these suits informally as “whistleblower” suits. However, this term is overly broad, as the U.S. has other whistleblower laws besides the False Claims Act.

History of Whistleblower Law

The U.S. Congress originally enacted the False Claims Act during the Civil War. This legislation was in response to widespread fraud by government contractors against the Union Army. Congress removed many of the incentives for whistleblowers to come forward in World War II.

Congress restored these incentives in 1986, and the number of qui tam suits has multiplied since then. Lobbyists for the healthcare and defense industries have often attempted to weaken the False Claims Act since 1986. However, these efforts have generally been unsuccessful. The U.S. government has recovered about $40 billion since the 1986 reforms. Whistleblowers have received over $4.2 billion of this total.

Qualifying Acts

The False Claims Act generally covers false claims in federally funded contracts and programs. These programs include Medicare and Medicaid. Specific acts include submitting false claims for payment or causing the submission of those claims. They also include making false statements to get fraudulent claims paid. The concealment of records of fraudulent claims is another violation of the False Claims Act. Additional acts that can result in a qui tam suit include conspiring to defraud the government.

The most common type of false claim is one for products or services the claimant never provided. It also includes payment claims that violate contract, regulations, and statutes. Each false claim may constitute a separate violation of the False Claims Act. This provision means that qui tam suits often charge the defendant with a large number of violations.

The deadline for filing a qui tam suit under the False Claims Act is the greater of the following:

  • Six years after the violation
  • Three years after the government should have known about the violation

In no event can a relator file suit more than 10 years after the violation.

Defendant Liability

The defendant in a qui tam suit is potentially liable for three times the value of damages to the government. The defendant is also subject to civil penalties for each false claim. These can include invoices, demands for payment and other payment documents. These penalties can range from $5,500 to $11,000 for each claim. Many specific documents can form the basis for a qui tam suit, depending on the industry. The forms for Medicare cases include the following:

  • Medicare enrollment forms
  • CMS Form 1500
  • Form UB-92
  • Cost report forms
  • New drug and abbreviated new drug applications
  • Pharmaceutical pricing reports

Pharmaceutical pricing reports include ASP data forms and Medicaid rebate quarterly reports.

Relator Compensation in Medicare Qui Tam Cases

A person must file a qui tam suit to be eligible for compensation under the False Claims Act. It isn’t enough to just inform the government about a false claim. Furthermore, the government must recover money as a result of the suit before the relator can receive compensation.

A relator should receive between 15 and 30 percent of what the government recovers. This range applies whether the case results in a settlement or favorable verdict. The exact amount primarily depends on the significance of the roles that the relator and government play in the case. A more significant contribution by the relator increases the compensation. A more significant contribution from the government decreases the compensation.

The relator’s compensation is generally between 15 and 25 percent of the recovered damages if the government joins the lawsuit. If the government doesn’t intervene, the relator should receive between 25 and 30 percent of the recovery. Each relator gets a portion of the total compensation in qui tam cases involving multiple relators. The individual contribution of the relator determines the portion each individual receives.

If you are aware of fraud, you have protection in Medicare qui tam cases under the False Claims Act. Contact the skilled attorneys at Bothwell Law Group by calling 770.643.1606 today.