Scope of Healthcare Fraud For Whistleblower Cases

The following is taken from an interview with Tony Munter as he discusses where healthcare fraud typically takes place and what makes it different from other types of whistleblower cases. Call today to schedule a consultation with a healthcare fraud False Claims Act lawyer.

Healthcare fraud whistleblower cases are not all federal. It’s a matter of federal and state law. There’s a federal False Claims Act and there are about thirty state False Claims Acts now. The thirty state laws vary quite a bit between laws that only go after medical claims and some that go after every kind of false claim.

I believe just about every state law that exists would go after a medical false claim. And so, because the states in addition to the federal government also spend a great deal of money on healthcare, most states have taken a position of enacting laws to allow them to also collect when there is a large scale fraud committed against them.

Does Healthcare Fraud Only Happen At Hospitals?

Healthcare fraud is not limited to hospitals. It happens anywhere. The government pays for any type of healthcare service. It could happen at a hospital, it could happen at home, it could happen at nursing homes, it could happen at the drug store, it could happen even in terms of submitting grant applications to the National Institutes of Health, and it could happen in terms of submitting a drug application to the Food and Drug Administration. There is all manner of healthcare fraud big and small unfortunately out there.

What Makes Healthcare Fraud Cases Different From Other Whistleblower Cases?

The huge difference between medical fraud cases and defense cases is the relationship between the government and the contractors is very different. In a defense case, the government is usually working with the contractor on a more intimate basis, meaning they know who the contractor is, they approve certain things, and they don’t approve certain things on a given project. The government may know what’s going on a little bit more clearly.

Usually that can make it a little bit more difficult for the contractor to commit fraud, but if they do, of course, it can be very serious indeed.

With healthcare, the government pays healthcare insurance bills and they pay the bills for patients in Medicare and Medicaid and Tricare, but they’re not the ones receiving the healthcare.

They may or may not be in a position to know if the actual care itself is needed. The government has no way of handling that and of tracking that, so the relationship to the service provider is a little remote. Essentially, the government just pays for it. As a result, it’s unfortunately a little easier for the government to get defrauded under those circumstances.

Securities fraud is a whole different ballgame because it’s not even the government that has to be defrauded. If it’s a violation of securities law, it’s possible to sue under the Securities and Exchange Commission Whistleblower Program. If the SEC or even the Commodity Futures Trading Commission finds a violation and sues under it, a whistleblower can obtain a reward, but it doesn’t have to be that the government is the injured party at all under those laws.