False Claims Act and Substandard Medical Care

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The False Claims Act is not only the best way to sue for fraud committed against the government, it can also be the best way to expose systematic abuse of patients in the health care system. Whether that abuse takes the form of adulterated drugs or substandard care provided at nursing homes or by hospice workers, it may be possible for an individual to report the problem through a case filed under this law.

To sue under the False Claims Act, there must first and foremost be a connection to government funds. Of course it is possible to sue for systematic substandard care under the False Claims Act if the government is paying for such services. Because these cases not only involve government funds — they also focus on the very purpose of government programs such as Medicare and Medicaid — they often receive support from government investigations. If you have further questions, contact a DC False Claims Act lawyer who handles substandard medical care FCA cases.

Proving Substandard Medical Care

Cases alleging that a doctor provided substandard care can be particularly difficult to prove, as they require demonstrating that the care was so poor that it was effectively worthless. Such a demonstration is difficult, except in the most egregious cases (e.g. amputating the wrong limb). Such cases are typically isolated and are also more appropriately litigated as medical malpractice. While medical malpractice is one kind of case an individual can pursue, it is not the same as a filing of fraud committed against the government. A single medical malpractice case may arise out of the negligence of a practice. Such a case obviously involves tremendous pain and suffering for an individual, but that is not typically what creates a case under the federal or state False Claims Acts. What leads to a false claim is some kind of systemic action which results in the government losing money.

However, health care service providers have been sued successfully for substandard care. If it can be shown that a health care provider’s services were effectively worthless, and the provider billed the government for that care, then prevailing in a false claim action is relatively easy.

Implied Certification Violations

Courts have found that worthless services are not services at all, and thus any claims for such services are explicitly false. Some courts have also upheld the so called “implied certification” theory in these cases, thereby finding that presenting a claim for worthless care is a false certification of compliance with the laws and regulations requiring that care to be adequate. That creates liability for such claims under the False Claims Act.

The area in which claims for substandard care have been relatively successful is when they are brought against nursing homes and other long-term care facilities that are accused of neglecting or even abusing their patients. In these cases, rather than focusing on specific medical procedures, it is possible to look at the conditions endured by the patients. If the living conditions are sufficiently poor as to be worthless — either due to dilapidation of a facility or worse — or if there is a pattern of abusive behavior, then all claims presented by these facilities to federal health care programs are explicitly or implicitly false.

Unfortunately, these cases do in fact occur and more regularly than anyone would like. It is a shame that it may take a federal lawsuit to expose and improve the conditions at such facilities. Patients are particularly vulnerable both to abuse and to the health threats that can come from living in substandard conditions. Since most of these facilities survive on government funds, it is possible that the False Claims Act can be used to address these issues.

The False Claims Act Addresses Abuse

When patients have been harmed and when the government has lost money as a result, the FCA may be the best way to address these abuses. While many of those on the front lines of health care do not like to think about the financial rewards inherent in False Claims Act litigation, there is a larger point to the financial aspect of improving long-term care facilities through this law. Sometimes it is necessary to spread the word that abusive facilities are subject to the triple damages and civil fines that are applicable under the False Claims Act. Hopefully, as word gets out, such facilities will choose to improve their practices rather than face the possibility of such potentially devastating legal liability.