Whistleblower Claims

Healthcare providers are under strict regulations to charge for their services. Failure to comply with federal laws could mean extra fees for a hospital or healthcare provider, Medicare or Medicaid exclusion, a revoked medical license, or even prison terms for those involved. That does not stop many healthcare providers in the U.S. from committing healthcare fraud, and recent years have been rife with examples. As an experienced whistleblower claims attorney, we can guide you through the process, whether you need to report a crime or defend against one.

Qui Tam is Latin for “Who brings the action to the king as well as for himself.” Medicare Qui Tam involves an individual suing or for false claims or Anti-Kickback/Stark Laws. Under the False claims act, an individual who initiates legal action or blows the whistle receives a portion of the litigation or settlement, going as high as 30% of the total.   

Whistleblowers can also claim recoverable damages throughout a Qui Tam case. If a whistleblower has lost income, sustained emotional stress, or faced alerting the government about healthcare fraud, then compensation can be paid for those circumstances.

Types of damages include:

• Economic Damages
• Emotional Distress or Harm
• Punitive Damages

Economic damages like lost wages are easier to measure since it requires keeping track of how much income you have lost due to being fired or unable to find work after blowing the whistle.

Emotional distress or harm can manifest as depression, anxiety, and physical pain from a healthcare provider’s retaliation against a whistleblower. Damages can be recovered for any of these outcomes as well. Punitive damages meant to punish a defendant for wrongdoing can also be rewarded, but this is rare since the prosecution has to prove that the employer acted out of malice.

2020 was a landmark year for medical fraud cases., The Department of Justice (DOJ) charged 345 defendants across 51 federal districts, including over 100 doctors, nurses, and other licensed medical professionals, submitting $6 billion in fraudulent claims to federal health care programs and private insurers.

The fiscal year 2020 was also when the DOJ recovered $2.2 billion in settlements under the False Claims Act, $1.8 billion of which came from Qui Tam, or whistleblower suits. Since Congress bolstered the False Claims act in 1984, over $64 billion have been recovered by the DOJ. Much of that comes from whistleblower cases.

Aside from government investigators, qui tam is a crucial way healthcare providers get caught when engaging in fraud. Any employee at a healthcare practice, including nurses, doctors, billing managers, or licensed medical professionals, can blow the whistle and notify the government of any illegal activity.

If you are a healthcare provider facing a fraud suit, or you are an employee at one that has either blown the whistle or plans to, contact the Norman Spencer Law Group, PC. We specialize in healthcare fraud defense and federal government investigations.

Common Examples Medicare Qui Tam Cases and Healthcare Fraud

• Fraudulently billing for Medicare, Medicaid, or Tricare expenses
• Billing for medications or treatments that are not medically necessary or not provided
• Charging payment for services rendered for procedures that are required for other operations performed on the same day (known as unbundling)
• Increasing cost on a treatment that was billed correctly at a lower rate initially (known as upcoding)
• Violations of Stark Laws, Anti-Kickback Laws, or the False Claims act by any doctor, pharmacy, lab, supplier, healthcare provider, or licensed medical professional
• Recovery under Medicare’s Incentive Reward Program
• Fraudulent billing for durable medical equipment (DME) or genetic testing for cancer/drug addiction

Qui Tam cases can be brought forward by anyone with knowledge of Medicare fraud or a false claim that has been made. This means that anyone from healthcare professionals with inside knowledge to public individuals that know about an instance of fraud can become a whistleblower. Anyone who initiates a Qui Tam case is called a “relator.” It is the relator’s job to represent the government when taking Medicare fraud cases to court.

Keep in mind that Qui Tam action may not go forward if it is based on publicly available knowledge or information revealed during public proceedings. The only time public information can be used in a Qui Tam case is if the relator is the information source before it becomes public.

A relator cannot take Qui Tam action if a private individual has already brought a similar Medicare Qui Tam case to court. Another thing to note is that cases cannot be based on hearsay and require actual evidence to go forward. Evidence can include billing records, internal communications, or other relevant documents.

Finally, it is essential to keep the statute of limitations in mind. In New York, Qui Tam case statute of limitations is either six years from the date of the healthcare violation or three years since the government either knew about or should have known about the violation.

When a Medicare Qui Tam action is filed, the relator gives the DOJ a copy of the complaint, remaining under seal for 60 days. After that time, the DOJ has 60 days to investigate the case and decide whether to get involved. Usually, the DOJ chooses not to intervene but reserves the right to step in at any point during the court proceedings.

Government involvement alters the settlements for the relator. If the DOJ does not intervene, then the relator and the prosecutors can get up to 30% of the total settlement as compensation. That amount is typically lowered if the government gets involved.

Medicare Qui Tam cases are often very involved, take a lot of time, and require specific expertise in healthcare procedures. These cases need a lawyer that is intimately familiar with the ins and outs of Medicare fraud.

At Norman Spencer Law Group, PC, we specialize in investigations into healthcare fraud, either for the government or on behalf of a healthcare provider. Our attorneys have represented clients throughout New York for years in healthcare fraud settlements.

If you are in a situation where you have information on Medicare fraud and have blown the whistle, or if you are a healthcare provider that has been named in a Medicare Qui Tam case, give us a call. Individuals will not have to pay for any action taken forward and even receive a sum of the settlement rewards.