Unnecessary medical billings is one of the biggest opportunities for individuals to defraud the government.

Given the size of the healthcare economy in the United States, it’s not surprising that unnecessary medical billings serve as a potential area for individuals to defraud the government under the False Claims Act. But one of the key parts of the False Claims Act is the qui tam or whistleblower provision. It allows whistleblowers to receive a reward or bounty for helping recover money for the federal government. It is this qui tam provision that helps combat fraudulent activity in the healthcare setting.

Qui Tam Provision

The qui tam provision is also known as the whistleblower provision of the False Claims Act. It provides a reward for individuals who help the government recover stolen money. The reward can range anywhere from 10% to 30% of the amount recovered. This percentage of recovery will vary based on several factors. These factors can include how much assistance the whistleblower provides in prosecution of the fraud, whether the whistleblower did anything illegal themselves to defraud the government and whether the government prosecutes the violator itself or relies on the whistleblower. In most cases, the relator can expect to receive anywhere between 15% and 25%.

As a general rule, the more work the whistleblower has to do to recover the stolen money, the higher reward percentage the whistleblower can expect. Actually participating in the fraud can lower the total amount the whistleblower recovers. However, it will rarely completely eliminate the reward. This is because the federal government knows that sometimes it has to pay a little money to a guilty party so that it may recover a lot of money from other guilty parties.

When Does the Whistleblower Provision Apply?

The False Claims Act covers situations where an individual or company defrauds the federal government for goods or services. Because of the high cost of healthcare in the United States, a lot of government money goes to helping individuals pay for healthcare services. Much of that money funnels through government-sponsored social welfare programs. This creates a wealth of opportunity for insurance companies, hospitals and other healthcare providers to defraud the government. Therefore, problems with medical billing will often come into play when dealing with the whistleblower provisions of the False Claims Act.

Medical Billing under the False Claims Act

Much of the expense of healthcare in the United States revolves around medical services. This can include physical exams, surgeries, medical analysis and testing. Another major healthcare expense deals with paying for medications. Both medications and professional services show up on medical bills. And when someone from the healthcare industry tries to defraud the federal government, evidence will almost always appear in the medical bills themselves.

For example, let’s say the violator is overcharging for a procedure. The higher price charged will appear on a medical bill. If the violator is mischarging the federal government, then the medication or procedure the government paid for but no one received will appear on a medical bill. The unnecessary medical billings will serve as evidence of fraudulent activity.

Therefore, it should come as no surprise that whistleblowers will commonly identify potential fraud in medical bills, as well as use those bills as proof that fraud exists. Often, when an individual wants to serve as a whistleblower, they must provide proof of fraud to the federal government. Documents, including medical bills, serve as persuasive evidence concerning fraudulent activity against the federal government.

Not only do the medical bills support the fact that fraud exists, but they can help calculate the cost of the fraud. Medical bills will show how much money the violator charged the government. The government can then compare this amount to how much the charge should have been. This amount can sometimes exist on another medical bill.

Assessing Medical Fraud Damage

With these two numbers, the government can identify the fraud and calculate how much money they improperly paid. There’s also the ability to identify how often fraud took place. This is important because each instance of fraud is subject to a penalty that ranges from between roughly $5,500 and $11,000.

Finally, all this documentation matters for whistleblowers because it can help calculate how much their reward under the qui tam provision will be. Remember, a whistleblower can receive up to 30% of the total amount the government can recover from the violator. Without knowing how much fraud took place, the whistleblower can’t accurately determine how much the government should recover. From the typical whistleblower’s point of view, the reward is the single biggest reason for blowing the whistle.

Have You Found Potential Fraud in Medical Bills?

Click to find out more about unnecessary medical billings issues by contacting Bothwell Law Group online.