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.
Department Recovers Over $2.2 Billion from
False Claims Act Cases in Fiscal Year 2020,”
Office of Public Affairs, January 14, 2021.
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
Agrees to Pay $900 Million to Settle
Allegations Related to Improper
Physician Payments,” (Sept. 26, 2022).
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.
Act Settlements and Judgments Exceed $2
Billion In Fiscal Year 2022,” (Feb. 7, 2023).
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.
General, “Attorney General James Helps
Shut Down Purdue Pharma, Secures $4.5
Billion from Sackler Family for Role in
Fueling Opioid Crisis,” (July 8, 2021).
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.
