What is a qui tam lawsuit?

A qui tam lawsuit allows private citizens to sue on behalf of the government when they have evidence of fraud against federal programs. Successful whistleblowers, called relators, receive a percentage of any recovery.

How much can a healthcare fraud whistleblower recover?

Relator awards under the False Claims Act range from 15-30% of the government's recovery, depending on whether the government intervenes in the case.

Am I protected from retaliation if I report healthcare fraud?

Yes. The False Claims Act includes anti-retaliation provisions. Employees who face adverse employment actions for reporting fraud may recover reinstatement, double back pay, and compensation for litigation costs and attorney fees.

Healthcare Fraud Whistleblower Attorney Massachusetts

Healthcare Fraud Whistleblower Representation

The False Claims Act allows individuals with direct knowledge of fraudulent Medicare or Medicaid billing, Anti-Kickback Statute violations, or systematic healthcare abuse to file qui tam actions on behalf of the government and recover a percentage of any proceeds.

Whistleblowers earned $309 million in 2020 for exposing U.S. government fraud.

Common Healthcare Fraud Schemes

Fraudulent billing encompasses a range of distinct schemes. Upcoding involves billing for services at a higher intensity or complexity than those actually rendered. Unbundling disaggregates procedures that should be billed as a combined service to inflate reimbursement. Phantom billing generates charges for services never provided to the patient.

Kickback arrangements implicate the Anti-Kickback Statute when referral sources receive compensation in any form, including consulting fees, speaker honoraria, free equipment, or discounted services, in exchange for directing patients or business to a provider. These arrangements pervade relationships between hospitals, pharmaceutical manufacturers, medical device companies, durable medical equipment suppliers, and laboratory services.

Additional violations include billing for medically unnecessary procedures, falsifying diagnoses to justify treatment protocols, misrepresenting the credentials of personnel providing care, and cost report fraud in institutional settings.

Overview

The Department of Justice recovered $2.68 billion in False Claims Act settlements in fiscal year 2023. Whistleblower cases accounted for 86% of that total.

In 2022, a single whistleblower case resulted in a $900 million settlement with Biogen, demonstrating the immense power individuals have to expose corporate wrongdoing and protect public interests.

Qui Tam Process in Massachusetts

A qui tam complaint is filed under seal in federal district court. The complaint and supporting materials remain confidential while the Department of Justice and relevant agency conduct their investigation. The initial seal period is 60 days by statute, but extensions are routinely granted in complex matters involving voluminous records or multi-defendant schemes.

Government intervention is the outcome relators seek. In intervened cases, the government assumes primary litigation responsibility, and the relator typically recovers between 15 and 25 percent of any proceeds. When the government declines to intervene, the relator may proceed independently. Relators in non-intervened cases who pursue the action to a successful resolution typically receive 25 to 30 percent of the recovery.

The False Claims Act’s anti-retaliation provisions protect whistleblowers who face adverse employment action as a consequence of protected activity. Employees subjected to termination, demotion, suspension, or workplace harassment may recover reinstatement, double back pay, and compensation for litigation costs and attorney fees.

Healthcare fraud remains the largest source of False Claims Act recoveries, with over $1.7 billion recouped in 2022 alone, partly due to whistleblower lawsuits.

Statute of Limitations

Claims must be filed within six years of the violation, or within three years of the date the government knew or reasonably should have known of the relevant facts, whichever is later. In no event may an action be brought more than ten years after the underlying violation. Identifying the applicable limitations period requires careful analysis of when the government had constructive knowledge, which varies by agency and enforcement context.

Purdue Pharma’s $4.5 billion settlement highlights the vital role of whistleblowers in combating corporate-caused public health crises.

What to Bring to a Consultation

Qui tam matters live or die on documentation. Relevant materials typically include internal billing records, electronic health records, remittance advice and explanation of benefits documents, communications reflecting billing directives, compliance memoranda, and any written policies that diverge from actual practice.

Consult counsel before collecting or preserving documents. The scope of permissible document retention varies depending on employment agreements, computer access policies, and applicable professional obligations. Early engagement allows us to provide guidance on evidence preservation that protects both the integrity of the claim and the relator’s professional standing. Healthcare fraud claims in Massachusetts frequently involve parallel consumer protection theories and employment retaliation protections.

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