False Claims Act Healthcare Fraud Lawyer


Health care fraud is a major problem in the United States and the False Claims Act, or FCA, may just be the most effective way to fight it. The vast majority of successful cases brought under the False Claims Act (FCA) involve health care fraud. This is due primarily to the government’s deep involvement in funding health care at every level.

According to the U.S. General Accountability Office, in Fiscal Year 2014, the Medicare program will be required to cover more than 50 million elderly and disabled beneficiaries at an estimated cost of $595 billion. Massive as that amount is, it does not include the full scope of government programs that deal with paying for health care in the United States. Medicaid and Tri-Care Veteran’s benefits also pay money for the care of individuals. Individual government employees also, of course, have health care paid for with government funds.

All kinds of claims and all kinds of issues create liability for false claims under the federal and state False Claims Acts. One of the most likely areas of potential fraud involves claims for treatment which is not medically necessary. Others include:

Medical Necessity is Required

In order for any health care provider to charge a government program for services they must establish that those services are medically necessary. The point of the Medicare and Medicaid programs is to cover medical care. These programs are not designed to pay for, and are not expected to pay for, services which do not reach that standard. Medical necessity is an inherent requirement for all claims presented to the government under these programs.

That is why it is possible to sue when an institution regularly authorizes tests, which are not needed, or surgical procedures, which are not necessary for the care of a patient. Not only do those kinds of charges create fraud against the government, which is charged for these procedures, they also subject patients to potential harm from unneeded procedures.

Simply put, if the hospital or even a chain of hospitals is regularly billing for care without establishing that care is medically necessary chances are at least some of the bills they send out will be paid by a government program and will subject the provider to FCA liability. The majority of states also have their own False Claims Act laws, which create liability to the states for Medicaid payments when those payments are made for medically unnecessary care.

Medicare Regulations

Generally speaking, medical necessity must be established as a condition of payment for government programs. Medicare regulations specifically state that they do not cover procedures that are purely cosmetic. The same set of regulations also requires documentation of the medical necessity to be kept by the provider. Therefore, when providers bill for care which they cannot establish as medically necessary, they can be held liable under the False Claim Act.

Each claim presented to the government includes at least some form of a certification that the care was medically necessary. If it turns out that care was not necessary, the certification is violated and it is relatively easy to establish that the claim should be held liable under the False Claims Act. As such, providers will be subject to three times the damages caused to the government and civil fines for each false claim.

If the medical necessity was said to exist, but in fact did not, that can create additional liability under the act for maintaining false records and providing false statements to the government as well.

FCA Fights Health Care Fraud

It is simply not possible to violate this basic requirement of the Medicare program and also not create liability under the False Claims Act. Facilities that abuse the trust of the government by routinely performing unnecessary procedures or prescribing treatment for which there is no medical necessity will, sooner or later, find themselves on the wrong end of a False Claims Act case. The only reason to routinely charge the government for unnecessary procedures is to make more money.

These devious and deceptive tactics cause the government to waste money that should be spent on patients with legitimate health concerns. Also, unnecessary treatments may result in patients being subjected to a procedure or treatment which may actually be detrimental to their health. Therefore, fighting these abuses with the False Claims Act is not only justified, it may be best use of the law.

Filing a Healthcare Fraud Whistleblower Claim

Anybody with the appropriate information can file a healthcare fraud whistleblower claim. Specifically, anyone who knows about healthcare fraud that isn’t known generally and publicly—that isn’t all over the news already—can file a healthcare fraud claim. Just to reiterate, anyone with real information about healthcare fraud can file.

Now, I say that and sometimes we get phone calls from people who personally have been or feel that they have been defrauded by an individual healthcare provider. Technically, that very well could be the case, and I would never say it’s not exactly a case. With that said, it’s very difficult to use the False Claims Act to pursue an individual case of one person’s treatment being wrong or one prescription being inappropriate or medically unnecessary.

Those types of cases are more typically a medical malpractice claim. The False Claims Act is really about finding a systematic attempt to defraud the government. Defrauding the government at this level typically involves multiple cases of medical fraud of billing and charges that leads to the government being ripped off.