Qui Tam / Whistleblowers

Qui Tam Lawsuits and The Whistleblower/Relator Whistle

Qui Tam is derived from the Latin phrase "qui tam pro domino rege quam pro se ipso in hac parte sequitur," originally meaning "he who pursues this action on our Lord the King's behalf as well as his own."

Qui Tam actions are brought by a private persons, on behalf of the government under the Federal Civil False Claims Act (FCA). The FCA sets out civil and criminal penalties for persons who knowingly submit false claims to the Government for payment or approval. A lawsuit may be filed against the alleged false claimant by the government itself, or by a private person in the form of a "Qui Tam Civil Action" which is taken for that person and the government. This private person then receives some part of the recovery awarded for helping uncover and prosecute fraud against the government.

Violations of the False Claims Act give rise to enormous monetary liability. As of August 1, 2016 the per claim penalties has increased to $10,781 to $21,563 per violation and the FCA provides that all damages are trebled which amounts to 3 times the total amount of damages sustained by the government.

Whistleblower/Relator Payouts

The individual whistleblower who brings this action is known as a RELATOR. This Relator through his or her attorney files a lawsuit (under seal) in the name of the U.S. Government charging fraud against a person or company who knowingly presented a false or fraudulent claim to receive government funds. This Relator can share in any money recovered by the Government and typically receives between 15 to 30 percent of the recovery.

In the fiscal year 2016, the Justice Department (DOJ) recovered more than $4.7 billion in settlements and judgments. In cases filed by Relators the DOJ recovered $2.9 billion dollars. Out of those cases the Relators/Whistleblowers received $519 million in the fiscal year 2016 alone. From 2009 through the end of the Fiscal Year 2016 the Government recovered nearly $24 billion dollars in connection with Qui Tam cases and paid those Whistleblower/Relators more than $4 BILLION dollars!

Uncovering Qui Tam Cases

Typically a Relator possesses information to which the general public does not have access. However, it is important to know that firsthand knowledge is not required to pursue a Qui Tam case. Relators are often employees, former employees, competitors, contractors or subcontractors. Ask yourself or your friends and family these questions:

  1. Do you work for or know of a company or person that contracts with any governmental entity (federal, state, county or local) to provide goods or services to that governmental entity?
  2. If your answer to question 1, above, is yes, are you aware of any business practices by your employer, or a company or person connected to any government contract that could be characterized as wrongful, fraudulent or illegal? 
Types of Qui tam Cases

Qui Tam cases can involve submitting false claims to governmental agencies such as Health and Human Services, Housing and Urban Development, Environment, Energy, Education, NASA, Agriculture and Transportation. Right now, a significant amount of fraud cases being filed are focused on the HEALTHCARE INDUSTRY such as pharmaceutical manufacturers, medical device companies, hospitals, nursing homes, laboratories and physicians and involve governmental medical health programs such as Medicare; Medicaid, and Tri-Care (military). These types of Medical Fraud include:

  • "Off-Label Marketing" - Pharmaceutical Companies marketing their medication or medical devices for something other than what it has been approved by any regulatory or governmental body.
  • “Phantom Billing” – billing for tests not performed.
  • Performing inappropriate or unnecessary procedures.
  • Charging for equipment/supplies never ordered.
  • Billing Medicare/Medicaid for new equipment but providing the patient used equipment.
  • Billing Medicare/Medicaid for expensive equipment but providing the patient cheap equipment.
  • A drug or equipment supplier completing a Certificate of Medical Necessity (CMN) instead of the physician.
  • “Reflex testing” – Automatically running a test whenever the results of another test fall within a certain range, even though the reflex test was not requested by the physician.
  • “Defective testing” – When a test or part of a test was not performed because of technical trouble but is billed for anyway.
  • “Code Jamming” – Laboratories inserting or “jamming” fake diagnosis codes to get Medicare/Medicaid coverage.
  • Offering free services or supplies in exchange for your Medicare/Medicaid number.
  • “Unbundling” – Using two or more Current Procedural Terminology (CPT) billing codes instead of one inclusive code for a defined panel where the rules and regulations require “bundling” of such claims. Submitting multiple bills, in order to obtain a higher reimbursement for tests and services that were performed within a specified time period and which should have been submitted as a single bill.
  • “Double Billing” – charging more than once for the same service, for example by billing using an individual code and again as part of an automated or bundled set of tests.
  • “Up Coding” – Inflating bills by using diagnosis billing codes that indicate the patient experienced medical complications and/or needed more expensive treatments. (examples: billing for complex services when only simple services were performed, billing for brand-named drugs when generic drugs were provided, listing treatment as having been for a more complicated diagnosis than was actually the case.
  • “Phantom Employees” – Expensing employees or hours worked that do not exist.
  • “Improper Cost Reports” - Submitting false cost reports seeking higher Medicare reimbursements than permitted by actual facts.
  • "Kickbacks" - paying kickbacks to health care providers to induce the use of specific goods or services reimbursed by the government.
  • "Reverse" false claims liability - When someone has an obligation to pay the government money and hides that obligation or doesn't pay it or lies about the obligation to pay.
Anti-Retaliation

The FCA and the Fraud Enforcement and Recovery Act prohibits the employer from harassing or retaliating against the employee for attempting to uncover or report the fraud. If they retaliate the relator may be entitled to reinstatement, back pay, two times the amount of back pay, litigation costs, and attorney’s fees. If you have evidence of fraud against the government, you should find an experienced attorney who understands the complicated components and requirements of filing a Qui Tam Action.

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