ATTORNEY NEWSLETTER
Allegedly Improper Submissions For Payment
Physician Blows Whistle
How False Claims Cases Work
The majority of fraudulent claims submitted to the government for payment arise from the healthcare sector. Overbilling government health programs like Medicare, Medicaid and the Veterans Administration are major forms of this type of fraud. Billing for unnecessary services is also a recurring kind of healthcare fraud, as the case discussed below illustrates. Whatever the fraud when citizens sue the wrongdoer on behalf of the government the cases are brought in federal courts throughout the country under the False Claims Act, (“FCA”), 31 U.S.C. § 3729 et seq. The private individuals bringing the cases are referred to as “relators,” and the cases themselves are called “qui tam” cases. If the government recovers, the individuals bringing the lawsuits are eligible for rewards. 31 U.S.C. § 3730(d). Relators of fraudulent conduct are often employees or managers, or former employees or managers, or (in healthcare cases) patients of the business engaging in the fraud. If you have credible information of fraud against the government in violation of the FCA in San Francisco or elsewhere in California, call us today at (415)441-8669 and we can help. Our toll-free number is 1-888-50EVANS (888-503-8267).
Recent Settlement[1]
In a recent press release by the U.S. Department of Justice (DOJ), a medical laboratory and three of its owners have agreed to pay the United States $13,619,660.18 to resolve allegations that they violated the False Claims Act (FCA) by submitting or causing the submission of claims to Medicare for lab tests that were not ordered by health care providers and were not medically necessary. The settlement resolved allegations that defendants submitted or caused to be submitted claims to Medicare for medically unnecessary polymerase chain reaction (PCR) urinalysis laboratory tests that were not ordered by treating physicians. When a physician ordered a urinalysis (UA) with culture and sensitivity (C&S) or just a C&S, defendants allegedly automatically performed, and submitted claims for payment to Medicare for, a urinary tract infection (UTI) panel of tests by PCR (the UTI PCR Tests). Medicare reimbursements for the UTI PCR Tests were significantly higher than reimbursements for a UA with C&S — on average, Medicare paid approximately $11 for a UA with C&S but paid an additional $573 for a panel of UTI PCR Tests. A physician, whose patients were tested by the defendant lab, blew the whistle on the overbilling.
“Laboratories are permitted to bill federal healthcare programs only for medically necessary tests that are actually ordered by physicians,” said Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division. “The department will continue to hold accountable those who seek to misuse federal healthcare programs for their own financial gain.”
How A Qui Tam Action Begins
Any False Claims Act whistleblower case begins by a relator filing a complaint under seal in the federal court usually for the United States District Court for the district where defendant is located or does business. At the same time, the relator submits a disclosure to the DOJ outlining the material evidence the relator has of the alleged false claims. 31 U.S.C. § 3730(b). The seal period of the complaint lasts 60 days during which the DOJ investigates the claims. 31 U.S.C. § 3730(b)(2). (If necessary, the government can, and often does, extend the 60-day period during which the allegations are kept under seal.) If the government decides to intervene in the case, the government essentially takes over the litigation. 31 U.S.C. § 3730(c)(1). If the government declines to intervene, the relator may proceed with the litigation on his or her own. 31 U.S.C. § 3730(c)(3).
Contact Us
If you have credible information of government fraud in San Francisco or elsewhere in California, call Ingrid M. Evans at (415) 441-8669, or toll-free at 1-888-50EVANS (888-503-8267) or by email at <a href=”mailto:info@evanslaw.com”>info@evanslaw.com</a>. In addition to FCA and CFCA whistleblower cases, Ingrid and Evans Law Firm, Inc. also handle bank fraud whistleblower cases under FIRREA/FIAFEA, commodity trading and securities fraud under the Commodities Futures Trading Commission Whistleblower Program and the Securities and Exchange Commission Whistleblower Program, and tax fraud under the Internal Revenue Service Whistleblower Program.
[1] Evans Law Firm, Inc. was not involved in the case in any way.
