Types of Healthcare Qui Tam Cases

Fraud and abuse account for nearly ten percent of total government Medicaid and Medicare spending—approximately $120 billion per year.

The potential harm caused by fraud in the healthcare industry is substantial, given that total U.S. healthcare spending reached $2.9 trillion in 2013 alone.

Below are common types of qui tam cases pursued in the area of Medicaid and Medicare healthcare fraud.

Common Types of Healthcare Fraud Qui Tam Cases

1. Medicaid/Medicare Fraudulent Billing Qui Tam Cases

False Claims Act (FCA) qui tam cases in healthcare often involve:

• Total neglect or no services rendered
• Worthless or inadequate services
• Inferior medical products
• Aggressive or unnecessary treatments
• Misrepresentation of inpatient data

Each represents a possible violation when claims are submitted for services not actually performed or justified.

2. Treatment Issues

Whistleblower cases frequently arise from fraudulent treatment practices, including:

• Total neglect or no services provided
• Worthless or inadequate services
• Failure to meet the standard of care
• Aggressive or excessive treatment

3. Misrepresentation of Credentials

Healthcare fraud can occur when providers misrepresent the qualifications or credentials of individuals performing medical services.

Submitting claims under false pretenses may constitute a violation of the False Claims Act.

4. Upcoding or Improper Coding of Services

When submitting Medicare reimbursement claims, providers must accurately document and code the services rendered.

Improper coding or “upcoding” to increase reimbursement is a common form of healthcare fraud.

5. Bundling and Unbundling Procedures

While not always an FCA violation, improper bundling and unbundling can result in duplicate or inflated billing.

Some providers bill for a bundled service, then unbundle it into multiple claims to receive double reimbursement.

6. Misrepresentation of Patient Data

Errors or falsifications in patient data—such as incorrect treatment locations or service details—can lead to inaccurate billing and false claims.

7. Anti-Kickback Qui Tam Cases

Federal Medicare statutes prohibit pharmaceutical manufacturers, physicians, and pharmacies from receiving compensation in exchange for patient referrals or orders for goods and services.

Violations can trigger serious civil and criminal penalties.

8. Self-Referral Qui Tam Cases

Under the Stark Law, physicians are prohibited from referring patients to entities with which they have a financial relationship.

These laws aim to prevent self-referral abuses and reduce overutilization driven by personal profit motives.

9. Best Price Qui Tam Cases

“Best Price” cases often involve the manipulation of drug pricing or reimbursement structures.

Although the system has evolved, oversight remains critical to prevent manufacturers and providers from exploiting pricing mechanisms.

10. Best Value Qui Tam Cases

The Federal Acquisition Regulations (FAR) require fair and competitive pricing in government acquisitions.

Violations occur when healthcare entities manipulate bidding or pricing to secure favorable terms at taxpayers’ expense.

11. Off-Label Marketing Qui Tam Cases

The FDA must approve all prescription drugs sold in the U.S. for specific uses.

When pharmaceutical companies promote drugs for unapproved (“off-label”) uses, they may be liable under the False Claims Act if such marketing leads to improper reimbursements.

Federal Oversight and Enforcement

The staggering extent of healthcare fraud has led to increased federal scrutiny and enforcement.

These fraudulent activities—ranging from overcharging to billing for unperformed services—undermine trust and waste billions in public funds.

The government continues to expand investigations and penalties to safeguard taxpayer money and protect the integrity of the healthcare system.

The Role of Whistleblowers

If you have witnessed fraudulent activity, taking action can protect patients, hold wrongdoers accountable, and recover taxpayer dollars. Whistleblowers may also be eligible to receive a percentage of any funds recovered by the government.

Coming forward helps direct public healthcare funding toward legitimate patient care rather than fraudulent practices. If you believe healthcare fraud is occurring, this may be the right time to speak with an attorney and understand your legal options.

Notice

This website is designed to provide general information only. This information is not and should not be construed to be legal advice. The transmission of the information found on this website also does not result in the formation of a lawyer-client relationship.

You should be aware that qui tam claims are subject to a Statute of Limitations. The area of limitations periods is complex. There are also first to file rules, public disclosure bars, original source issues, and varying limitations in pursuing retaliation claims. If you wish to pursue your claims, you should promptly seek the opinion of an attorney regarding the merits of your qui tam claim and the applicable statute of limitations.