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What Is Qui Tam in Healthcare – Is It Ethical?

Doctor holding pen and chart

People who blow the whistle on healthcare organizations who are conducting fraudulent activity are responsible for restoring billions of misspent tax dollars back to the American government. You may work in healthcare and suspect illegal activity. Whatever type of fraud you’re suspecting, you’re likely wondering whether it’s ethical to whistleblow or even sue a healthcare facility. Well, the answer is yes.

What is qui tam in healthcare, though? You need to be sure you’re onto the right things. Qui tam involves government funds so it’s first of all restricted to Medicaid and Medicare services. We’re going to detail 10 of the most common types of qui tam lawsuits in healthcare. These are:

Out Of Interest, What Does ‘Qui Tam’ Mean?

Qui tam comes from the Latin phrase, ‘Qui tam pro domino rege quam pro se ipso in hac parte sequitir.’ Which, in a non-literal English translation, means that the person who sues on this particular issue does so for the good of their self and the King (i.e. the country and everyone within it).

So, qui tam in healthcare come into effect when you’re helping to stop American tax dollars being wasted through these billing scams.

Billing For Services Not Provided

The scope for this is quite wide. It includes any type of service which was charged but not given, such as a doctor billing for an x-ray or a blood test when the patient never actually received such a service. It relates to most areas of healthcare, including dentists, chiropractors, paramedics, mental health practitioners, podiatrists, pediatric specialists, physical therapists, GPs and even pharmacists.

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Billing For Medically Unnecessary Services

A patient may come in complaining of severe headaches and migraines. The hospital provides relevant treatments, such as MRI and CT scans. If you notice that the patient is also given treatments that are not relevant, such as a foot and legs x-ray, then this is fraud. The fraudulent party may find those services profitable so take the chance to exercise them.

Medicare and Medicaid pay only for items that are deemed medically necessary. If they pay for anything that wasn’t, the hospital has committed fraud.

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Upcoding, Unbundling, and Double-Billing

Upcoding is the act of overstating billing in order to get more money. For example, a doctor submitting a bill for a 1-hour examination when in reality they looked over the patient in a matter of minutes. Another example is a patient who has an infection. There are two antibiotics which can be used to ease the infection. One is much cheaper than the other. The doctor issues the cheaper one but charges for the more expensive.

Medicare and Medicaid often bundle certain services together for a lower price. A common service which gets bundled together is blood tests, where a single amount of blood is taken to test for several things, say cholesterol, pH imbalance, glucose and coagulation. Under Medicare and Medicaid, these would be bundled together for a lower, discounted price. Unbundling is the act of charging for the four separate blood tests when they should be charged as one.

Double billing is the act of charging for a bundled set of tests and unbundled tests at the same time. It also covers the act of charging twice for the same procedure through Medicare/Medicaid and then also through a private insurance company.

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False Prices and False Cost Reports

Pharmaceutical companies, pharmacies, hospitals and healthcare providers have to report the costs and price information to Medicare and Medicaid in order to establish rates. Submitting the false price and cost is fraud. For example, reporting that an appendectomy costs $35,000 when it actually costs $28,000.

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Inadequate Medical Documentation

Any healthcare provider is required to submit and maintain documentation which shows what services were rendered, how much they cost and when they occurred. If an investigation finds that they have missing or incomplete documentation, it can indicate fraud.

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Patient Not Eligible For Reimbursement

A common type of healthcare fraud is related to patients who are not eligible or enrolled on Medicare or Medicaid. Healthcare facilities may bill Medicaid and Medicare for treatments, items or services for patients who are not eligible in an attempt to fraudulently gain money from the state-funded insurance.

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Off-Label Marketing Of Pharmaceuticals

Any pharmaceutical drug comes with a prescribed use. This could be for specific use, for example to treat headaches, high-cholesterol, or heartburn. It also dictate the usage (take once a day or with every meal) and sometimes can be labeled with age restrictions, for example, not to be used by over 70s. This is known as the label use. Any use of the drugs which is not prescribed by the pharmaceutical company is known as off-label use and is illegal as it is not officially approved by the pharmaceutical company.

If a physician or healthcare provider promotes the use or writes a prescription for a drug to treat something ‘off-label’ then this is fraud, and Medicare and Medicaid should not be paying for it.

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Physician Self-Referrals

The Stark Law prevents physicians from referring patients to medical facilities where they, or a family member, has a financial interest. That could be, if they have stakes in a physiotherapy clinic or their sister owns a specialist liver treatment facility, or if their uncle is a dentist. If said physician referred a patient to any of those places for Medicare or Medicaid to pay for, they would be committing fraud.

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Prescription Fraud

Prescription fraud comes in a few different types. The first is healthcare providers, such as pharmacists, selling medicine to people who don’t have a prescription. Prescription fraud is also for pharmacists who alter someone’s prescription in order to charge Medicare and Medicaid for a higher dosage. Cases of patients paying their doctors to write them a prescription are also classed as prescription fraud.

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Unlicensed/Unqualified Providers

Medicare/Medicaid cannot be billed for services unless the provider has all licenses and qualifications. This could happen across all types of healthcare providers, including dental care. Dentists could bill for services rendered by an unlicensed dental hygienist, which is illegal.

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These are the most common types of Medicare and Medicaid Fraud which would result in a qui tam lawsuit. If you suspect any of these types of fraud, you should consult with an attorney immediately. Certain whistleblowing cases have a ’30 days to file’ limitation. So you need to seek expert advice immediately.

Every state has different whistleblowing laws and requirements. Once you begin a case against your employer, they may retaliate. It’s a courageous decision and the government rewards you for your bravery. If successful in proving your case in a court of law, the government compensates you with 10%-30% of the recovered funds. This means that, if you show your employer to have fraudulently obtained one million dollars, you would receive between $100,000 and $300,000. It’s definitely worth pursuing then, you just have to make sure you’re fully informed.

What Do You Need To Know?

If you’re still unsure whether you need to speak to an attorney, find out more information by downloading our comprehensive guide to qui tam whistleblowing. Find out everything you need to know. From key legal terms, what the warning signs of each type of Medicare and Medicaid fraud, what to do next and what a lawsuit would be like. It also provides details on what the laws are for employer retaliation in each state. Some states have whistleblower protection laws to help keep you safe. Get answers to all your questions by downloading our free whistleblowing guide.

Disclaimer: This blog is intended as general information purposes only, and is not a substitute for legal advice. Anyone with a legal problem should consult a lawyer immediately.