Building a Healthcare Fraud Whistleblower Case

With healthcare fraud, government money involves either Medicare, Medicaid, Tricare, or some other kind of government employee healthcare program. Under all of these programs, you and your False Claims Act healthcare fraud lawyer are entitled to file if government money is abused in any way under the federal False Claims Act.

Under many states, if it is a Medicaid state health insurance program, the state laws allow you to file a False Claims Act case under one or another state’s False Claims Act and it is possible to file that all at once in a consolidated action. If somebody has knowledge of a nationwide scheme to defraud, it may be possible to file in more than one jurisdiction all at once under state and federal False Claims Act laws.

Cases Involving Healthcare

With healthcare fraud, there are a lot of particular issues regarding regulations affecting Medicare. If someone can show examples that the practice was a condition of payment, that Medicare then would not have paid the claims if they had been aware of what was going on. For example, there is the Anti-Kickback statute, that is in itself a law designed to prevent unfair inducements from affecting medical judgment and referrals within healthcare, which can get technical quickly.

Sometimes, healthcare fraud can be a straightforward case involving someone billing more than they should have been. But when looking at healthcare fraud cases, there is special sensitivity to any fraud someone practices that also compromises the health care itself and causes the patient harm. Everybody is sensitive to these types of cases and in a routine kind of way, patients subject to any type of harm for no reason, such as if a particular procedure is being ordered to make money as opposed to for the benefit of the patient. There could be a False Claims Act case and because it would affect the health of many patients, people tend to be more sensitive to that fact too.

In health care, the reason the government tends not to notice fraud is that its relationship to the service is a more removed. The government pays for healthcare, but the government is not the receiver of the health care. The receiver of the health care is one individual.

If that service is defective or wrongful, the government may not have a way of determining what was wrong about the service. In healthcare cases, it is easy to separate out the government from knowledge of the fraud. In other areas, that can become an issue. Government contracting and government building are very complicated and not every government administration has the opportunity to review every document. Many government contractors stand almost in the shoes of the government while administering major contract. So it is not always clear that the government knew what someone might think they would have known in a government contracting case.

What to Look for in a Prospective Healthcare Fraud Case

Healthcare fraud is not about a doctor or nurse making a mistake, this is not medical malpractice. Officials pursue healthcare fraud cases to know where the government lost money and how the government was cheated out of money.

It is about a situation in which a service provider, medical device manufacturer, or a pharmaceutical company puts business ahead of the care of the patient and bills that way on a systematic basis. It is a systematic kind of a fraud, not an individual medical mistake or issue. It is not about a mistake in judgment by professional, but rather about a system to treat the federal government or a state government’s money unfairly and bill for stuff that should not be billed for.

Why File a Whistleblower Case Instead of Going to the Press

There is a public disclosure bar which makes it difficult to collect on a case based on any information that is in the public domain. Thus, by filing a case you can show that you are the original source and the public disclosure bar has been to some degree lessened by amendments of False Claims Act, but not entirely. It complicates a claimant’s ability to file a case if you go to the press. You can go to the press later after the case has been filed after the case has become unsealed, which is more the appropriate time and a smart thing to do. Before you know what your rights are and before you know what is going on, that is not the appropriate time to be going to the press, and obviously while the case is under seal of the court you cannot go to the press.