Articles Tagged with False Claims Act

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medicare fraud
In the world of False Claims Act qui tam cases, the concept of medical necessity is a very big issue.

Medicare Fraud

This is because Medicare requires, as a condition of coverage, that services delivered to a patient be “reasonable and necessary for the diagnosis or treatment of illness or injury.”  See 42 U.S.C. § 1395y(A)(1)(a).  Healthcare providers who wish to participate in the Medicare program must ensure that their services are provided “economically and only when, and to the extent, medically necessary.”  See 42 U.S.C. § 1320c-5(A).  In other words, Medicare only pays for services that are “medically necessary.”

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False Claims Act Cases

The Department of Justice recently announced its tally of total recoveries for 2016 under the False Claims Act.   The government recovered an astonishing $4.7 billion during this time.

The DOJ press release shows the following trends.

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Anyone reading this blog probably knows that we represent whistleblowers who file so-called “qui tam” cases under the False Claims Act.  The term “qui tam” is a Latin term derived from the longer and ancient legal expression “qui tam pro domino rege quam pro se ipso in hac parte sequitur,” meaning one “who pursues this action on our Lord the King’s behalf as well as his own.”  In short hand, that means an action brought by a private citizen on the government’s behalf, whereby the government and the individual will share in any of the money recovered.  The False Claims Act is one of the few provisions in federal law that allows a private citizen to file a case on behalf of the government.

Qui Tam Cases

Because qui tam actions are brought on behalf of the government, the government is the “real” plaintiff in the case, and the whistleblower or “relator,” is functioning more like a private attorney general.  As a result, the False Claims Act requires that the government have a shot at pursuing the case on its own.  To give the government this opportunity, when a relator files a case, it must be filed “under seal” for a period of at least 60 days.  That means that the existence of the case remains secret and cannot be disclosed without the court’s permission to anyone other than (a) the relator, (b) the court, and (c) the government.

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whistle  A whistleblower is a person who reports fraud, corruption or other wrongdoing, usually, but not always, at their place of work.  Most states have laws that protect whistleblowers and prohibit employers from firing, demoting or retaliating against whistleblowers.

When a whistleblower sees fraud committed against the government, he or she has the opportunity to become a qui tam whistleblower under the False Claims Act, which is a federal law that encourages whistleblowers to report fraud and thereby receive a reward for their efforts.

We often get the question, “How do I become a whistleblower?”

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A study done by the National Contract Management Association revealed that in 2014, at close to three billion dollars, the Department of Defense accounted for two-thirds of the nation’s corporate contract spending.  This vast amount of money, however, provides ample incentive for dishonest contractors to bilk the government and taxpayers, and potentially put the lives of U.S. military members at risk.  One defense against these unscrupulous fraudsters is the False Claims Act.

During the Civil War, dishonest contractors sold the Union Army decrepit horses, faulty weapons, and rancid food. In response, Congress passed the False Claims Act on March 2, 1863. Abraham Lincoln was President when the False Claims Act was passed and it is sometimes referred to as the “Lincoln Law.”

The False Claims Act permits private individuals to bring lawsuits on behalf of the government for the fraudulent conduct.  The qui tam provision of the False Claims Act provides that the whistleblower who brings the action may share in any recovery by the government.

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How do you know if you have a Qui Tam Case?

Under the False Claims Act, persons who know about fraud against the federal government can receive a reward for reporting that fraud and helping the Government recover money from the wrongdoer.    We receive many calls from potential whistleblowers who wish to report serious fraud against Government.  Unfortunately, we cannot take every case where fraud exists.   Here is a list of sample questions to help you determine whether you might have a potential False Claims Act qui tam case.

  1. Does your employer do business with the federal or state government?  This would include Government vendors or contractors as well as healthcare companies that receive payment from Medicare or Medicaid.
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If you are considering blowing-the-whistle on government fraud, you are probably wondering what happens once you file a qui tam lawsuit under the False Claims Act. The False Claims Act, 31 U.S.C. § 3729 et seq., contains a very detailed process for bringing a whistleblower case.

Steps involved in a qui tam case

Before the qui tam complaint is filed, the whistleblower (also called the “relator”) must make a “pre-filing disclosure” to the government through his or her attorney.  The pre-filing disclosure contains substantially all of the evidence that is known to the relator about the fraud.  The pre-filing disclosure is not filed with any court and is not available to the defendant.

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Deadly Healthcare Fraud in Florida and Beyond

Do you think Medicare and Medicaid fraud is a victim-less crime? Think again.  Many times, health care fraud only causes monetary damages to the government and taxpayers.  Depending on the type of fraud, however, it can also result in injuries to or even the death of Medicaid and Medicare beneficiaries.  Unscrupulous fraudsters who fail to provide adequate care required by Medicare and Medicaid, not only scam the government and taxpayers, they put innocent lives in jeopardy.

Take for example a recent criminal healthcare fraud case in Maryland against Alpha Diagnostics, LLC, a portable diagnostic services provider of x-rays, ultrasounds, and cardiologic tests.  According to the Department of Justice, the testimony and evidence presented at trial showed Alpha defrauded Medicare and Medicaid by falsely representing that the tests had been interpreted by licensed radiologists, when in fact, the tests had only been reviewed by non-physician employees of Alpha.  In furtherance of the fraud, Alpha employees allegedly created fictitious reports purportedly created by an actual licensed physician to which they would forge the licensed physician’s signature.

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The United States is currently at war with the People’s Republic of China – a trade war.  The False Claims Act has an important role to play in this battle.

Every year foreign countries, but most particularly China, engage in a practice of “dumping” goods into the U.S. market.  Generally, this occurs when a foreign country exports goods into the U.S. at a sales price below the producer’s own cost of production.  Often, this takes place because the foreign manufacturer is receiving an unfair subsidy from its own country that makes the U.S. sales price extremely low.   The bottom line is that Chinese manufacturers can sell goods at prices so cheap that it creates an unfair advantage and materially harms U.S. producers of the same goods.

When the government determines that U.S. domestic industries are being materially injured by this type of “dumping,” the government can impose anti-dumping duties or countervailing duties to offset the unfair advantage enjoyed by the foreign manufacturer.  In plain language, this means the importer of these foreign goods must pay an extra fee in order to bring these cheap goods into the United States.   The extra fee is designed to make the foreign goods more expensive so that U.S. industry can remain competitive.

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What is a Violation of the False Claims Act?

Any fraud on a federal government agency could potentially be a violation of the federal False Claims Act.  Not every government fraud involves millions of dollars.  Take, for example, a recent settlement announced by the Department of Justice’s Office of the Inspector General.

According to the DOJ’s press release, Douglas daCosta of Livermore California, a former federal law enforcement agent in the San Francisco field office of the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF), has agreed to settle allegations that he submitted false claims to the federal government for paid sick leave when he wasn’t sick. Wait. What? An employee got in trouble with the federal government for playing hooky from work?  Yes.