Healthcare Qui Tam Cases

Part 2 of the “National Whistleblower Litigation” Video Series

Fraud and abuse accounts for almost ten percent of total government Medicaid programs and Medicare spending on healthcare, or approximately $120 billion per year. The potential harm caused by fraud in the Medicaid/Medicare healthcare industry cannot be overstated: total spending on healthcare for 2013 alone reached $2.9 trillion. Below are the types of qui tam cases often pursued in the area of Medicaid fraud / Medicare healthcare fraud.

  • Medicaid/Medicare Fraudulent Billing Qui Tam Cases – False Claims Act (“FCA”) qui tam claims involving Medicaid/Medicare healthcare vary. Categories often involve allegations of total neglect or no services, worthless services, inadequate and inferior services and products, aggressive patient treatment, and misrepresentation of inpatient data. More types of fraudulent billing qui tam cases are as follows.
  • Treatment Issues – There are five areas in which qui tam cases arise in the area of treatments for which healthcare fraud and medicare fraud claims are submitted. They include total neglect or no services provided, worthless services, inadequate services, standard of care, and aggressive treatment. 
  • Misrepresentation of Credentials – Another area of fraud cases in healthcare occur when a healthcare provider submits a false claim under the FCA for misrepresenting the credentials of the person that provided the services. Cases involving misrepresentation of credentials may involve a wide variety of factual scenarios.
  • Upcoding or Improper Coding of Goods and Services – When submitting a claim for Medicare reimbursement to the government, the claimant must provide documentation that supports the claim. Appropriate documentation usually involves correctly coding services to enable the government to reimburse the healthcare provider. 
  • Bundling and Unbundling Procedures – This is not an FCA violation. Although, many providers will bundle services to receive reimbursement for one procedure, and then submit another claim in which the same procedure has been unbundled into separate procedures to receive a second reimbursement on the same service provided.
  • Misrepresentation of Patient Date – Populations – Many physicians and care providers provide services for patients either in a nursing home, where the patient resides, or in the physician’s office. This causes billing inaccuracies that could translate into false claims. 
  • Anti-Kickback Qui Tam Cases – Medicare statutes prevent pharmaceutical manufacturers, physicians, and pharmacies from receiving anything in return for the referral of patients or for the ordering of any goods or services. 
  • Self-Referral Qui Tam Cases – The Stark Act is designed to prevent abusive self-referrals by physicians. It also aims to stop the overutilization by physicians who could profit by referring patients to entities for financial gain.
  • Best Price Qui Tam Cases – Although revisions are being made, the system has put the entire process into the hands of the very people who abuse the system. 
  • Best Value Qui Tam Cases – Acquisitions are generally made according to the policies and procedures explained in the Federal Acquisition Regulations, which allows the government to solicit competitive pricing for CME acquisition. 
  • Off-Label Marketing Qui Tam Cases – The Federal Food and Drug Administration must approve all prescription drugs sold in the United States. The FDA also reviews a proposed drug’s safety and efficacy. 

For more information and case citations, please see Androphy “Federal False Claims Act and Qui Tam Litigation,” published by Law Journal Press (2010). This book provides comprehensive coverage of the interests of all the participants in qui tam cases including the relator, defendant corporation, federal and state governments, and courts. It also provides analysis of the latest cases and whistleblower statutes.


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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 or law firm regarding the merits of your qui tam claim and the applicable statute of limitations.