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Understanding Qui Tam in the Healthcare Industry

What is qui tam in healthcare? “Qui tam” in the healthcare industry is when a qui tam attorney handles cases involving a direct party—typically an employee or former employee—bringing a false claims act case of fraud against the federal government. These cases are filed under the False Claims Act (FCA), a federal law developed to expose fraud and protect the government against any false or fraudulent claim.

Many healthcare fraud activities involve Medicare fraud or Medicaid fraud, both of which are federal health care programs to pay for medical services. If you suspect such activities, consulting a Medicare billing fraud lawyer can provide the expertise needed to navigate the complexities of these cases. Qui tam lawsuits can also include nursing home fraud, pharmaceutical company fraud, medical device companies fraud, hospice or home health fraud, and various healthcare scams.

Here are a few examples of healthcare fraud activities that might be involved

  1. Billing for Services Not Provided: Submitting fraudulent claims for medical services, procedures, or durable medical equipment that were never provided.
  2. Upcoding: Billing for medically unnecessary services that are more expensive than the ones performed.
  3. Unnecessary Services: Delivering medically unnecessary services that are more expensive than required.
  4. Misrepresenting Diagnoses: Falsifying diagnoses to justify medically unnecessary services or higher charges.
  5. Creating False Documentation: Generating a false record that supports false or fraudulent claims.
  6. Using Another Provider’s Number: Billing under the provider number of different health care providers than the ones who performed the procedure.
  7. Lack of Supervision: Performing medical procedures without a physician supervising, violating healthcare provider regulations.
  8. Backdating Procedures: Submitting false claims for procedures done when the patient was not insured.
  9. Kickbacks and Stark Law Violations: Paying or receiving incentives for referrals.
  10. Overflow Billing: Charging for more medicine than was actually administered.
  11. Off-label Marketing: Promoting pharmaceuticals for uses not approved by the FDA.

Essentials for Filing a Healthcare Qui Tam Case

Determining if you have enough information to file this type of case can be challenging. However, understanding the essentials that your attorney needs to prove qui tam cases can guide you. Think of it as packing for a family summer vacation: making a list ensures you don’t forget anything important. Similarly, having a checklist of necessary information can help your case.

Here are key elements your healthcare qui tam attorney will need:

  1. Evidence of Fraud: Concrete proof of fraudulent activities, such as billing records, internal emails, or witness testimony. In such situations, a False Claims Act lawyer can assist in gathering and presenting the necessary evidence effectively.
  2. Details of the Fraudulent Claim: Specific instances of a false or fraudulent claim submitted to federal health care programs.
  3. Identification of Fraudulent Parties: Names of individuals and healthcare providers involved in the fraud.
  4. Impact on Federal Funds: Evidence showing how each fraudulent claim paid led to the misuse of government funds.
  5. Violation of Federal Law: Private citizens or whistleblowers must show proof that the fraudulent activities violated the federal False Claims Act.

How do you know whether you can report fraud

You may wonder if you have enough evidence for filing a healthcare 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.

Leaving everything to memory and guesswork means you’ll be likely to forget something important. If you make a list of all the essentials, you stand a much better chance of succeeding in your qui tam action. You know that will save you time- and probably a whole lot of hassle and expense versus gathering information off the cuff.

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

YOUR HEALTHCARE QUI TAM ATTORNEY NEEDS TO KNOW THE TIMEFRAME

One of the first things to knock off your qui tam case checklist is the timeframe of the fraudulent activities. Under the False Claims Act (FCA), there is a statute of limitations of six years for false claims. Some circumstances may fall outside this boundary, but your attorney needs to know when the health care fraud took place.

Documentation of dates can be one of the most powerful pieces of evidence in a healthcare qui tam case. This record will serve to prove the timeframe is within the statute of limitations for false claims act cases.

YOUR HEALTHCARE QUI TAM ATTORNEY NEEDS TO HAVE CREDIBLE INFORMATION OF FRAUD

You may be aware of a fraudulent claim made at your place of employment due to your expertise and experience. Your healthcare qui tam attorney will talk with you about the information you are aware of and help determine if it is credible enough. 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 healthcare qui tam attorney, bring any proof you have as evidence of the fraudulent act. Your evidence for the qui tam action can include things like healthcare providers’ 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 filing a case.

YOUR HEALTHCARE QUI TAM ATTORNEY NEEDS TO DETERMINE IF YOU ARE AN ORIGINAL SOURCE

Only one person can file a particular qui tam lawsuit, especially when addressing False Claims Act violations. If the fraud and earlier filed suits have already come to the attention of the government, you cannot file a separate case. Your attorney will research and determine if you qualify as the qui tam relator of the alleged fraud. If you are the primary source, what you know comes from inside information, not from something you read about or heard about somewhere else.

YOUR HEALTHCARE QUI TAM ATTORNEY NEEDS EXPERIENCE TO PROVE A CASE

It’s important to choose an attorney who knows qui tam law in the healthcare field. The details matter in any lawsuit, and with qui tam cases, there are an awful lot of federal agencies involved as well as 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 whether you should proceed on your own or not. Choose legal counsel who has successfully argued healthcare 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 healthcare qui tam whistleblower attorney by contacting the Bothwell Law Group online.

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