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Qui Tam / False Claims Act: Healthcare

One area in which false claims frequently arise is the healthcare industry. Oftentimes, healthcare fraud goes unnoticed because many patients fail to read their medical bills carefully and simply are not aware of the many different types of healthcare fraud schemes that exist. If you believe a healthcare professional or hospital is engaging in illegal conduct, contact an experienced qui tam attorney at Willoughby Brod today to learn how our attorneys can help with your whistleblower case.

The California False Claims Act

After the federal False Claims Act (FCA) was enacted in 1986, California enacted its own version of the Act called the California False Claims Act (CFCA). Modeled after the FCA, the CFCA is very similar to the FCA with the exception of about 10 minor differences, several of which are listed below:

  • Under the FCA, the Attorney General or other prosecuting attorney has authority to issue Civil Investigative Demands. This is not the case under the CFCA.
  • Both the FCA and CFCA impose liability on individuals who buy or receive public property in exchange for payment of a debt or obligation from someone who is unable to sell or pledge the property. However, under the CFCA, the property may be received from any person, whereas under the FCA, the property must be received from a government officer or employee.
  • One provision that is found in the CFCA that is not mentioned in the FCA is the imposition of liability on “passive” beneficiaries who unknowingly benefit from the submission of a false claim, find out the claim was false, and fail to report it.
  • Joint and several liability exists under the CFCA but not under the FCA.

The purpose of the CFCA was to create a cause of action against individuals and companies that knowingly submit false or fraudulent claims for payment, misappropriate public property, or avoid paying what they owe to the state of California or to local governments. Violation of the CFCA is a civil offense and can result in fines of up to three times the actual harm to the state, plus a fine of $5,500 to $11,000 for each violation of the CFCA.

Qui Tam Provision

Under the CFCA’s qui tam provision, a whistleblower is permitted to file a claim under the Act. A whistleblower is an individual who informs on another individual or organization engaged in illegal conduct. Once a whistleblower files his or her lawsuit, which is kept under seal, the Attorney General or other prosecuting attorney may conduct its own investigation into the claim and may choose to intervene in the whistleblower’s lawsuit. If the Attorney General or local prosecuting attorney successfully prosecutes the case, the whistleblower may receive a portion of the reward, up to 33% in some cases. Since whistleblowing cases are quite complex, it is advisable to contact an attorney to assist you in filing your whistleblower claim.

Healthcare Fraud

One industry in which whistleblowing is more common due to higher levels of fraud is the healthcare industry. By familiarizing yourself with the most common types of healthcare fraud, you can equip yourself to be better able to detect healthcare fraud in your day-to-day life and report it under the CFCA.

Common Types of Healthcare Fraud

Below is a list of the most common types of healthcare fraud:

  • Billing for services that were never performed: Your doctor might throw in an extra service code or two, especially if you already had a relatively long list of services on your bill and a couple of extra service codes can easily go unnoticed.
  • Billing at a higher rate: Your doctor might bill you for a longer visit than you had or bill for a surgery when you merely went in for a regular check up.
  • Billing for a service that was never required: Your doctor might prescribe you a procedure you do not need just so he or she can bill for it.
  • Double billing: Your doctor might file multiple claims for the same service.
  • Prescribing unnecessary drugs: Your doctor might prescribe you drugs that you do not actually need just so they can bill for it.
  • Misrepresenting the location of service: Your doctor might give you a home treatment kit but bill for treatment in house.
  • Misrepresenting the medical professional who provided the treatment: Your doctor might bill at a treating physician rate even when you never saw a treating physician and only saw a nurse or hospital staff.
California Whistleblower Protection Act

You may be worried about the repercussions of informing on a doctor, healthcare worker, or hospital, especially if the individual is your boss or if the hospital is your employer. Luckily, the California Whistleblower Protection Act protects against any type of employment retaliation as a result of whistleblowing. In fact, under the California Whistleblower Protection Act, any employer that retaliates against an employee for whistleblowing is required to reinstate the employee at the same seniority level he or she previously had, pay two times the back pay plus interest, compensate the employee for any special damages incurred, and at times, pay punitive damages. The employer will typically be required to pay the costs of litigation and attorneys fees, as well.

Contact Our Qui Tam/False Claims Act Lawyers Today

If you believe a healthcare provider or hospital is engaging in illegal conduct, contact one of the experienced qui tam lawyers at Willoughby Brod today so we can get started on your whistleblower claim. If you have already filed a whistleblower claim and have experienced retaliation from your employer as a result, give us a call at (800) 427-7020 to schedule a consultation with our attorneys. California law prohibits any type of retaliation due to whistleblowing, and our attorneys will fight to defend your rights. Contact us online or at (800) 427-7020 and find out how we can help.

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