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How Is the Validity of a Qui Tam Case in Healthcare Determined?

Qui Tam Case in Healthcare

Qui Tam Case in HealthcareA qui tam case in healthcare is one of the fastest growing claims in the last few decades, even surpassing military claims. Healthcare qui tam claims generally stem from improper or false billing for services or procedures, ‘off-label’ usage of FDA approved medications, or use of someone else’s health information to claim benefits.

Qui Tam Healthcare Cases and Whistleblower Laws?

Like any other qui tam cases, healthcare claims are covered by whistleblower laws. In a qui tam case, a person can raise a complaint on behalf of the government against individuals or companies that are behaving fraudulently.  Once a suit is raised, the government can investigate the whistleblower’s claims and choose to join the suit; if the suit is successful, the whistleblower (or relator) may receive a reward of up to 25 percent of the funds recovered by the government in the suit.

To protect a whistleblower from retaliation by an employer or others named in the suit, qui tam laws provide up to double the damages, plus attorney fees, for any retaliatory actions taken against a whistleblower.

How Are Qui Tam Cases Verified?

A qui tam case is not as simple as seeing an attorney and signing an affidavit. There are a number of steps you need to fulfill in order to file a valid qui tam suit:

  • You need to have credible evidence of wrongdoing committed by an individual or a company. The evidence needs to show either harm to the government, violation of the securities and commodities laws, or harm to employees or the general public.
  • You need concrete evidence of wrongdoing. Documentary evidence, while not required, will vastly increase the chance of government interest.
  • You need original evidence that cannot be gleaned from other sources. Evidence taken from public sources like the internet, TV news, or pubic government records cannot be used in a whistleblower claim.
  • You need to file right away. Under the ‘first to file’ rule, a whistleblower cannot file a claim if another whistleblower has filed one using the same evidence.
  • You need to remember the statute of limitations. It varies depending on the industry, but can range from 30 days to 6 years after the violations.

Can you Fake a Qui Tam Claim?

As with any suit, there may be unscrupulous folks who try to bring false claims under the False Claims Act.  This usually happens in order to collect rewards under the qui tam provision. These false claims will not hold up under scrutiny, nor will the evidence bear them out. Be aware that you may also be liable for perjury should you lie under oath.

Have questions about a qui tam case in healthcare? Call the Bothwell Law Group at (770) 643-1606.

What Are Qui Tam Actions in Healthcare?

qui tam actions in healthcare

qui tam actions in healthcareQui tam actions in healthcare make up a significant portion of the qui tam lawsuits brought by private individuals. This shouldn’t be surprising given the staggering size of the healthcare industry in the United States and the government’s need for healthcare services. The armed forces, Medicare, Medicaid and the Affordable Healthcare Act are just a few of the major examples of qui tam actions in healthcare.

What Is a Qui Tam Legal Action?

A qui tam legal action is where a private individual, called the relator, sues on behalf of the government. In the United States, the qui tam action falls under the False Claims Act.

Under the False Claims Act, anyone who defrauds the federal government can be liable for hefty financial penalties. Since much of the fraud against the government goes undetected, the enforcement of the False Claims Act relies heavily on whistleblowers to alert the government to the fraud and provide critical information as to what’s going on, who’s doing it, how long it’s been going on, etc. Almost three-quarters of all False Claims Act enforcement lawsuits are the result of a whistleblower first bringing the lawsuit through a qui tam legal action. If it weren’t for these whistleblowers, much of the money recovered by the federal government would not be possible.

Healthcare Spending by the United States Government

A qui tam lawsuit will work with healthcare company violators just as it would if the violator was any other company or government contractor. However, qui tam actions in healthcare are particularly notable for one reason: significant amounts of money are at stake.

There is a lot of money in the healthcare industry in the United States. One of the largest expenditures of the US government is paying for medical care of its citizens. For example, about 4% of the United States entire GDP (Gross Domestic Product) goes to Medicare and Medicaid programs. The GDP of the United States was about $18 trillion dollars in 2015. This means that in the Medicare and Medicaid programs alone, the federal government is spending hundreds of billions of dollars each year. That provides plenty of opportunities for unsavory companies and individuals to try and cheat the system and defraud the federal government. And we haven’t even discussed healthcare services for the military, the Affordable Care Act and Social Security benefits.

Qui Tam Actions in Healthcare

Another way that qui tam actions in healthcare are notable is because of the potentially high amounts of recovery that are possible under the False Claims Act. Punishment of a violator will consist of two components.

The first component deals with actual damages suffered by the federal government. The False Claims Act violator will pay three times the amount of actual damages. For instance, if a hospital overcharges the government by $1 million, it would have to pay $3 million in damages.

The second component deals with penalties for each false claim submitted to the government. Currently, each claim carries a penalty of anywhere between roughly $11,000 and $22,000. This amount can also go up each year as a result of inflation. When healthcare fraud occurs, it usually occurs many times.

Looking at the earlier example of a hospital overcharging the federal government $1 million of medical care, let’s further assume that the $1 million involved the treatment of 10,000 patients. This amounts to 10,000 instances of fraud against the federal government. Since each instance of fraud is subject to between $11,000 and $22,000 in penalties, the hospital may face anywhere from $110 million to $220 million in penalties. This is on top of the $3 million it must pay in damages.

Even though the fraud amounted to “only” $1 million or $100 per patient, the hospital must now pay at least $113 million in penalties and damages for its False Claims Act violations. Since the qui tam provisions of the False Claims Act allow relators to recover anywhere from 15% to 25% of the amount ultimately recovered by the federal government, relators have the potential to receive a very substantial reward. In certain instances, this reward can be as low as 10% or as high as 30%. Looking at the hospital hypothetical, a relator could potentially recovery anywhere from $11 million to $66 million.

But before you decide to go on a whistleblowing crusade to get this type of reward, understand that these rewards are relatively rare and may take many years to obtain. On the other hand, understand that this hypothetical isn’t too far-fetched, either.

Many of the largest False Claims Act recoveries have been in the healthcare industry. Take for instance the top 20 largest pharmaceutical company legal settlements in the United States, which ranged from $345 million to $3 billion – only two of them did not involve the False Claims Act.

Do You Have Questions about a Qui Tam Lawsuit In Healthcare?

Qui tam actions in healthcare can be quite complicated with all of the money at stake. If you think you may want to report healthcare fraud against the federal government, learn more by contacting the Bothwell Law Group.

What Does a Health Care Qui Tam Attorney Need to Prove a Case?

health care qui tam attorney

health care qui tam attorneyA health care qui tam attorney needs a case that involves a direct party—usually an employee or former employee—bringing a case of fraud against the government. It’s a case filed under the False Claims Act, which was developed to protect the government against fraud. Many circumstances leading to fraud involve

Medicare or Medicaid, both of which are federally regulated programs to pay for medical services. Health care qui tam cases can also include nursing home fraud, pharmaceutical fraud, medical device fraud, hospice or home health fraud and healthcare scams.

Here are a few examples of health care fraud activities that might be involved:

  • Billing for services not provided
  • Billing for more expensive services than the ones performed
  • Delivering more expensive services than were medically needed
  • Misrepresenting the diagnosis to justify payment
  • Creating false documentation to support payment
  • Billing under the provider number of a different doctor than the one who performed the procedure
  • Performing medical procedures without a physician supervising
  • Backdating procedures for a time the patient was insured
  • Kickbacks and Stark Law violations
  • Billing for “overflow” of medicine
  • Off-label marketing of pharmaceuticals

You may wonder if the information you have is enough to file a health care qui tam case. While every case is individual, knowing the basics of what an attorney needs to prove a case could help you determine if you’re heading in the right direction.

It’s like packing for the family summer vacation. If you leave everything to memory and guesswork, you’ll likely forget something important. If you make a list of all the essentials, you stand a much better chance of getting to where you’re going with everything you need. You know that will save you time- and probably a whole lot of hassle and expense than if you just pack off the cuff.

Here are some things your health care qui tam attorney needs to prove a case:

Your Health Care Qui Tam Attorney Needs to Know the Timeframe

One of the first things to knock off your qui tam case checklist is when the fraudulent activities took place. There is a statute of limitations of six years in false claims acts. Some circumstances fall outside this boundary, but your attorney needs to know when the fraud took place.

Documentation of dates can be one of the most powerful pieces of evidence in a health care qui tam case. This record will serve to prove the timeframe is within the statute of limitations.

Your Health Care Qui Tam Attorney Needs to Have Credible Information of Fraud

You may be aware of fraudulent activity at your place of employment due to your expertise and experience. Your health care qui tam attorney will talk with you about the information you are aware of and help determine if it is credible enough to provide the basis of a case. This information may be verbal, or you may have physical evidence. Physical evidence is tricky and can be difficult to obtain. Talk with an attorney who is knowledgeable about false claim act suits and he or she will be able to determine the credibility of what you know.

When you meet with your health care qui tam attorney, bring any proof you have as evidence of the fraudulent act. Your evidence can include things like receipts, copies of fraudulent paperwork or bookwork and other items that may be in your possession. Your attorney will have a staff to investigate and gather evidence and will assist you in determining if that evidence is sufficient for a qui tam case.

Your Health Care Qui Tam Attorney Needs to Determine If You Are an Original Source

Only one person can bring a particular qui tam case. If the fraud has already come to the attention of the government, you cannot bring a separate case. Your attorney will research and find out if you are the original source of the alleged fraud. Your information comes from inside information, if you are the primary source, not from something you read about or heard about somewhere else.

Your Health Care Qui Tam Attorney Needs Knowledge to Prove a Case

It’s important to choose an attorney who knows qui tam law in the health care field. The details matter in any lawsuit and with qui tam cases there are an awful lot of rules and regulations governing every aspect of the process. Also, if the government chooses not to intervene, you need an attorney with the wisdom to know if you should proceed on your own or not. Choose an attorney who has successfully argued health care qui tam cases in the past, so you can trust he or she will make solid decisions.

Learn more about the benefits of using a health care qui tam attorney by contacting the Bothwell Law Group online.