TYPICAL QUI TAM CLAIMS
Virtually anyone who receives money from the federal government or pays money to the federal government, can engage in conduct which would give rise to a qui tam violation. Activities which constitute a violation under the False Claims Act are: (a) knowingly presenting, or causing to be presented, to the federal government a false or fraudulent claim for payment; (b) knowingly using, or causing to be used, a false record or statement to get a claim paid by the federal government; (c) conspiring with others to get a false or fraudulent claim paid by the federal government; (d) knowingly using, or causing to be used, a false record or statement to conceal, avoid or decrease an obligation to pay money or transmit money to the federal government. Claims Against Providers of Medical Services, Supplies or Equipment A substantial portion of the monies recovered under the False Claims Act, involve cases against doctors, hospitals, clinics and companies or entities which were engaged in the practice of providing medical services, medical supplies and/or medical equipment. Medical providers such as these receive substantial monies from Medicare, Medicaid, TRICARE or other medical insurance programs which are funded in whole or in part, by the federal government. This gives rise to a wide variety of qui tam violations, the most typical of which are as follows: Billing for Brand - Billing for brand name drugs when generic drugs are actually provided. Bundling - Billing more for a panel of tests when a single test was asked for. Concealment - Failing to disclose, or taking affirmative acts to conceal billing errors which resulted in overpayment for services or goods provided. Double Billing - Charging more than once for the same goods or service. Equipment Billing Fraud - Billing for the use of new equipment, or premium equipment, when either used or inferior equipment is provided. Inflated Management Fees - Artificially inflating management fees in situations where the government pays management fees in connection with any provision of medical services, or in the conduct of government-sponsored medical research. Kickback Fraud - Prescribing a medicine or recommending a type of treatment or diagnosis regimen in order to win kickbacks from hospitals, labs or pharmaceutical companies. “Lick & Stick” - Prescription rebate fraud and “marketing the spread" prescription fraud both of which involve lying to the government about the true wholesale price of prescription drugs. Phantom Billing - Billing for tests, goods and services that were never delivered or rendered. Phantom Labor - Charging for employees that were not actually on the job, or billing for made-up hours to maximize reimbursements. Retention of Overpayments - Being overpaid by the government for a service or good, and then not reporting the overpayment to the government. Shelling - Setting up a shell company, or manipulating the mode or receiving payments for the purpose of inflating the rate of reimbursement to be received. Shorting - Charging for full quantities of prescriptions, when actually dispensing partial or short prescriptions. Signature Fraud - Forging physician’s signatures when such signatures are required for reimbursement from Medicare or Medicaid. Unapproved Billing - Filing claims for reimbursement of expenses and for services while knowing that such reimbursements and services were not covered by medicaid or medicare. Billing for unlicensed or unapproved drugs or devices. Unbundling - Using multiple billing codes instead of one billing code for a drug panel test in order to increase remuneration. Unwarranted Billings - Billing for services which were not reasonable or necessary, in frequency, duration, or at all. Billing for medically unnecessary tests. Automatically running a lab test whenever the results of some other test fall within a certain range, even though the second test was not specifically requested. Upcoding Diagnoses - Inflating bills by using diagnosis billing codes that suggest a more expensive illness or treatment. Upcoding Employee Work - Billing at doctor rates for work that was actually performed by a nurse or resident intern. Upcoding Services/Goods - Billing for a more highly reimbursed service or product than the one provided. Sales of Ordinary Goods or Services to any Agency of The Federal Government Virtually any individual or company which sells ordinary goods, merchandise or services to any branch or office of the federal government, may violate the False Claims Act. Some typical claims which have been filed against commonly known retailers are as follows: Failing to provide accurate pricing information in sales to the government. Failure to pass sales discounts on to the government. Retention of overpayments received from the government, and a failure to report such overpayment to the government. Overcharging the government for labor or services provided. Sales of goods from countries such as China and Taiwan, when such countries do not have reciprocal trade agreements with the U.S., and sales of goods from that country to the federal government are barred by the Trade Agreements Act. Sales of defective goods to the federal government. Claims Against Government Contractors Companies which enter contracts to provide goods and services to the government, which can range from simple office supplies, to military weaponry for the department of defense, are often the subject of major qui tam cases. Common examples of qui tam claims asserted against government contractors are as follows: Defective Goods - Selling defective goods to the government, selling the government used equipment as new equipment, and/or presenting broken or untested equipment as operational and tested. False Certifications - Providing false certification that a product meets specifications required by government. Providing false certification that products being supplied are being subjected to testing procedures in accord with government requirements, when such testing had not been performed. Providing false certification that minority or female contractors are providing services, or are the true principals of the company or companies providing services. False Testing - Submitting false service records or samples to show better than actual performance. Mischarging - Charging the government for labor or services not provided, or “mischarging time” expended on other matters. Billing for marketing, lobbying or other non-contract related activities. Nondisclosures - Failing to offer the same sales discounts to the government that sellers offer to private purchasers. Procurement Fraud - Providing false information to secure, or in securing contracts from the government. Failing to provide accurate pricing information in sales to the government. Retention of Overpayments - Being overpaid by the government for a service or good, and then not reporting the overpayment to the government. Claims Against City, County and other Local Governments Because they are recipients of large amounts of federal money, local governments can be defendants in qui tam actions. The most typical claims against local governments are as follows:
Claims Against Private Colleges and Universities Because they are the recipients of federal funding often in the form of federal research grants, or in relation to university operated clinics, colleges and universities have been subjected to successful qui tam claims in connection with their receipt and use of such monies. Common examples of qui tam claims against colleges and universities are as follows: Fraudulent Billing - The employ of fraudulent billing practices at University clinics and programs to obtain unearned medicaid funding. Grant Noncompliance - When a College or University fails to comply with the restrictions which govern the permitted use, method and manner of expending monies they have received from the federal government. Misappropriation - When a College or University uses funds received from the federal government for any purposes other than the specific purpose for which such funds had been given to them by the federal government. Phantom Research - Charging the federal government for research that was never conducted. Retention of Overpayments - When a College or University receives an overpayment of federal funds, or realizes a surplus from federal funds received, due to an expense being less than previously anticipated, and the official or local government fails to report the overpayment or excess to the federal government. While The False Claims Act does not cover tax fraud, there is a separate federal provision, 26 C.F.R. 301, which provides for rewards of 15% to 30% to persons who disclose large tax frauds to the Internal Revenue Service (IRS). Under the §301, if you are aware of a company or person who has defrauded the Internal Revenue Service (IRS), out of $2 million dollars or more, (including principal, penalties and interest), and the company or person has an annual income of at least $200,000 per year, you can file a formal written disclosure of the fraud with the IRS. If you do, and the IRS recovers money as a result of the information you provided, you will receive a reward, typically between 15% and 30% of any monies recovered by the IRS. For information about actual cases, go to the NEWS section. |