Whistleblowing on Health Care Fraud

This will be the start of a series of blogs of how to identify fraud and whistleblow on your company, co-workers, and bosses.  A Whistleblower is defined as one who reveals something covert or who informs against another.  A Whistleblower has a lot to lose and also a lot to gain (if you do it right), if you reveal fraud that is going on in your company.  Based on last weeks blog, there is an estimated annual fraud losses of more than $840 billion among organizations in the United States.  As a key employee at your company, you may be witnessing fraud everyday and may or may-not know it is occurring.  ReportMyCompany.com is a site that will help potential Whistleblowers gain the knowledge of what is consider fraud under the False Claims Act, IRS, and SEC.

The first case study that I will discuss will be on a health care Whistleblower that was awarded million in a Qui Tam lawsuit under the False Claims Act.  Don't just sit by and watch your boss commit fraud.

United States vs. Winter Park Urology Associates PA: 

Summary of Case: Qui Tam action by Whistleblower to recover damages and civil penalties arising from Defendants' actions in violating the False Claims Act.  Defendants knowingly presented or caused to be presented numerous false or fraudulent claims for payment or approval to federal healthcare programs; and knowingly made, used, or caused to be made or used false records or statements to get false or fraudulent claims paid or approved.

Whistleblower's Job Title: Director and Department Manager of Health Care Company.

Whistleblower's Knowledge:  First-hand knowledge of various ways the company deliberately sought to increase billings by submitting claims in violation of federal guidelines. The health care company routinely submitted claims for tests that were not medically necessary and not properly documented in the medical records. As a result, the health care company received millions of dollars from Medicare and other federal healthcare program that it was not entitled to receive.  

Violations Under the False Claims Act:   

(1) Knowingly presented or caused to be presented numerous false claims for payment or approval.

(2) Knowingly made, used, or caused to be made or used, false records or statements material to false or fraudulent claims, and to get false or fraudulent claims paid or approved.

(3) Knowingly made, used, or caused to be made or used, false records or statements material to an obligation to pay or transmit money or property to the Government, or conceal, avoid, or decrease an obligation to pay or transmit money or property to the Government.

(4) Knowingly concealed or knowingly and improperly avoided or decreased an obligation to pay or transmit money or property to the Government.

(5) Conspired to commit the above acts, and to defraud the Government by getting false or fraudulent claims allowed or paid.

Whistleblower Award:  Up to 30 percent of the proceeds of the action or settlement of the claims.  In addition, the Whistleblower was made whole for his unlawful termination, including reinstatement, two times the amount of back pay, interest on the back pay, and compensation for special damages.  Also, the Whistleblower was awarded all costs and expenses incurred, including reasonable attorneys' fees.

Related Links:  http://www.bizjournals.com/orlando/blog/2013/09/20-million-whistleblower-lawsuit.html?page=all

http://www.wftv.com/news/news/local/winter-park-medical-practice-accused-fraud/nFdSy/

http://www.nytimes.com/2010/02/26/us/26radiation.html?pagewanted=all&_r=0