It's no secret that the price of healthcare in the United States is on the rise. A large contributing factor to the rise in health insurance coverage is fraud which is committed against government programs offering healthcare, like Medicare and Medicaid. These programs provide hundreds of billions of dollars in healthcare costs each year, and some healthcare providers have found ways to make an additional profit from these programs, which only increases the costs of healthcare. Qui tam actions help to curb healthcare fraud by outing those who defraud government healthcare programs.
What are Qui Tam Actions?
Although the United States government is well aware that healthcare fraud exists, the government is unable to prevent the fraud in its entirety. Unable to control the situation on its own, our government has turned to its citizens--including Pennsylvanians--to help combat healthcare fraud, offering incentives through qui tam lawsuits.
This form of legal action--otherwise known as a "whistleblower lawsuit"--is a lawsuit brought under the federal False Claims Act. Qui tam lawsuits work to reward whistleblowers who are successful in helping the government recover money that was obtained by defrauding the government.
An Overview of the False Claims Act
The False Claims Act, 31 U.S.C §§ 3729-3733 is not a new concept--the statute was enacted by Congress in the mid-1800s to prevent military service members from defrauding the government. Under the False Claims Act, it is a crime to intentionally file a false claim with regard to a federal health care program. Specifically, the act penalizes a person who:
- Knowingly presents a false or fraudulent claim for payment or approval;
- Knowingly makes, uses, or allows the use of a false record or statement material to a false or fraudulent claim;
- Has possession or control over money meant for the government and knowingly delivers less than the total amount of money to the government;
- Creates or delivers a receipt without knowing that the information is true with the intent to defraud the government; or
- Conspires to commit any of the above actions.
The key element of all of the above actions is knowledge. If a person genuinely does not know that their reporting or payment is incorrect, a qui tam action will not survive. A person who knows that they are engaging in such an action, however, can be held liable for their actions.
Forms of Healthcare Fraud in Pennsylvania
Although the ways in which healthcare fraud can be committed in Pennsylvania and throughout the United States are virtually endless, there are many common forms of healthcare fraud. These forms of fraud include:
- Fake patients: in some cases, a medical provider may submit a claim for treatment or testing for a patient who does not actually exist.
- Services not performed: some healthcare providers attempt to make extra money from government healthcare programs by submitting a claim for treatments, testing, or prescriptions which were never actually given to a patient.
- Up-coding: this form of healthcare fraud occurs when a provider submits a medical claim for services or treatment that is falsely bolstered to allege a patient had a more complicated--and thus more costly--procedure than the procedure that actually occurred.
- Kickbacks: although prohibited by federal law, many healthcare providers receive special incentives including discounted equipment and referral fees.
- Billing separately: oftentimes, healthcare providers are reimbursed by the government at a discounted rate if certain procedures or tests are performed together. As such, an emerging common form of healthcare fraud is "unbundling"; this means procedures and tests normally performed together are billed separately.
- Unnecessary procedures: in order for a government healthcare program to reimburse a medical provider, the tests or treatments that were performed must have been medically necessary. In order to circumvent this rule and make additional money, some healthcare providers submit claims for procedures not serving any medical purpose.
- Incorrect medical records: in order to make additional money, a healthcare provider may falsify or alter a patient's medical records to show that a person suffered from a disease that was not actually present or received medical treatment that was not administered.
- Off-label marketing: this form of healthcare fraud occurs when a pharmaceutical company markets a prescription or product for uses not approved by the FDA.
- Price fraud: sometimes healthcare providers receive discounts from government healthcare programs, which are expected to be passed on to clients who use these government programs. Hiding this discount can create additional revenue for healthcare providers.
Typical Parties in a Pennsylvania Healthcare Fraud Qui Tam Lawsuit
- Qui tam Plaintiff: if you bring a lawsuit against a healthcare provider, you are considered to be a qui tam Plaintiff--in other words, you are the whistleblower who commences legal action against the person or organization defrauding the government.
- Healthcare provider Defendant: this is the person or company who is being accused of acting in a way that defrauds government healthcare programs.
- The United States Government: sometimes, the government itself will file a qui tam lawsuit under the False Claims Act. In this case, a private party may not be able to bring a lawsuit against the healthcare provider.
The Process of a Healthcare Fraud Qui Tam Lawsuit
Under the False Claims Act, any United States citizen can sue a person or business that is believed to be defrauding the government's healthcare system. These lawsuits are filed "under seal," which means that the lawsuits are kept private from everyone--even the entity who is being sued--until the government has an opportunity to investigate the accusations.
After a qui tam lawsuit has been filed, the Justice Department investigates the allegations made by the whistleblower Plaintiff. In rare cases, the government may "intervene" in the case, meaning that the government actually joins the lawsuit. Most of the time, the government does not intervene in a qui tam lawsuit--in these cases, the whistleblower may pursue the lawsuit on his own with the help of an attorney.
Following a finding of guilt, a Defendant who has defrauded the government can be forced to pay the government back for the fraud it has committed.
Legal Remedies for a Healthcare Fraud Qui Tam Lawsuit
Because the government is unable to prevent healthcare fraud on its own, incentives are provided to individuals who uncover healthcare fraud through qui tam lawsuits. A qui tam plaintiff is eligible to receive a portion of the total amount recovered by the government from healthcare providers who are found to be defrauding government healthcare programs. These incentives can be quite substantial depending on the amount of money subject to the fraud. In a qui tam action where the government intervenes, a whistleblower can be awarded 15 to 25 percent of the amount recovered by the government for the healthcare fraud. In cases where the government does not intervene and the Plaintiff decides to pursue the action on his own, the Plaintiff can be awarded anywhere from 25 to 30 percent of the amount recovered by the government.
The penalties that a healthcare provider can face if caught committing healthcare fraud are substantial--those who are caught can be slapped with a fine between $5,000 and $10,000 along with three times the amount of money that was defrauded from the government.
Ready to Blow the Whistle on Healthcare Fraud in Pennsylvania? We're Here to Help
If you believe that a Pennsylvania healthcare provider is defrauding the government in order to make money off of government healthcare programs, The Brod Law Firm is standing by to help you make your claim. If your claim is successful, you may be entitled to monetary compensation for your help. Don't wait any longer--to speak with a member of our legal team today, fill out an online case evaluation form or call us at 1-888-435-7946.