What Does Healthcare Fraud Mean in False Claims Act Cases?

If you think you may have a False Claims Act case in the health care industry, you may be wondering what “health care fraud” means in this context. Below, a Qui Tam healthcare fraud lawyer answers questions about health care fraud in False Claims cases. For more information contact a False Claims Act attorney today.

What is Healthcare Fraud in the False Claims Act Context?

That’s a good question. I think when people think about healthcare fraud, they’re thinking about bad medical practices and certainly that can become healthcare fraud but I’ll get to that in a minute. In the context of cases under the Federal False Claims Act, the question is has the federal government, or if it’s a state government that has False Claims Act, been defrauded in some way.

So, healthcare fraud in that context is a business issue. Has the government been billed for services that weren’t performed, billed for services at a higher rate than they should have been, or billed on unnecessary services?

Now, when there is healthcare fraud on the business side, it usually goes over onto the care of the patient side as well. Anytime there is a lack of medical necessity established and a procedure is done anyway, that can be healthcare fraud or, if a needed procedure is not done but charged for, then that is not only a bad medical practice but becomes healthcare fraud as well.

So, obviously these are intertwined issues. Anytime the government is charged for something that they really shouldn’t have been charged for—it can be a matter of healthcare fraud.

How Common Are Healthcare Fraud Whistleblower Cases?

Well, they’re the most common kind of false claims cases that are filed. Now, healthcare fraud obviously encompasses a great deal of sub industries such as pharmaceuticals, hospice care, nursing homes, and hospitals. So, it’s a pretty broad area for fraud to occur but there are many kinds of healthcare fraud cases and there are certainly many cases out there relatively speaking.

I should say that last year was the largest year for filings by individuals under the qui tam provisions of the False Claims Act. There were seven hundred and fifty two cases which includes all the cases individuals filed under the Federal False Claims Act cases and there were a few additional cases filed under state laws and stuff.

But, I guess my point is as much as we think of them as being a huge number of cases, that’s actually not that many if you consider how big the country is, how many hospitals there are, and how many pharmaceuticals.  Just because there are big cases and we hear about them all the time, there may not be as many out there as we really think. My sense is that there’s many different kinds of healthcare issues that are raised at a local level or reported to a local authority level that because they may not involve a significant amount of money  we may not hear about them as much.

It seems like a lot of healthcare fraud when you’re mostly handling False Claims Act cases, but compared to the size and scope of the federal budget maybe it isn’t as much as we think about.