Through Medicare and Medicaid, The U.S. government provides and subsidizes medical care for individuals who meet certain qualifying criterion. Doing so, comes at a hefty cost and during 2014 federal Medicare spending topped $618 billion while Medicaid spending totaled more than $495 billion.
Unfortunately, an unknown percentage of Medicare and Medicaid spending is generated to cover fraudulent health care claims. Under the False Claims Act, employees who blow the whistle on health care professionals and/or institutions that file claims with the government which contain false information and/or relate to unnecessary procedures, can file a qui tam lawsuit.
A case that's currently before the U.S. Supreme Court may expand the circumstances under which whistleblowers are allowed to file qui tam lawsuits. At issue in the case, Universal Health Services v. Escobar, is whether a whistleblower or the U.S. government can take legal action against a healthcare provider or institution under the False Claims Act's implied certification theory of liability.
Under the implied certification theory of liability, a payment request may be completely legitimate. However, if the government or a whistleblower can prove that "the provider billed for services while in violation of some government rule or regulation," a qui tam action can be filed.
Those within the healthcare field are anxiously awaiting the Court's decision in this case. An affirmative decision to "uphold the validity of the implied certification theory of liability under the FCA" would likely signal the filing of many more qui tam lawsuits.
Because tax dollars help fund the Medicare and Medicaid programs, fraud committed with regard to these programs ends up costing us all. Employees who have knowledge that an individual provider, hospital or medical clinic is submitting false or fraudulent claims for repayment, should discuss what they know with an attorney who handles qui tam lawsuits.
Source: Becker's Hospital Review, "The Supreme Court case that could expand false claims liability for hospitals: 10 things to know," Ayla Ellison, April 20, 2016