Typical Healthcare Fraud Whistleblowers

Health Care Employees

The most common of all healthcare qui tam plaintiffs are current or former employees.

Discovering fraud is virtually impossible without an insider’s cooperation. Employees who provide information and evidence of fraud against their employer make for a very strong case.

Without whistleblower assistance cases are based on only circumstantial evidence. Convictions and settlements are difficult of prove when this happens.

Investigators will attempt of find additional evidence to support an indictment. They will focus on current and former employees to find the inside information they need.

Subcontractors & Competitors

Less common type of healthcare whistleblower comes from a subcontractor or competitor to a healthcare provider. The reason is they normally lack the insider's knowledge to prove fraud is directly attributed to another company.

However, some knowledge of fraudulent behavior can strengthen any case. Reporting wasteful and misuse of government funds offers rewards.

Healthcare Experts

Healthcare experts have an in-depth knowledge of the industry, especially in a particular field.

This expertise allows them to provide the proper evidence and facts needed to pursue a successful qui tam lawsuit.

Attorney Tip: As a third-party that can prove fraudulent behavior, you need legal protection and guidance. Proper rules and regulations need to be followed so you do not expose yourself to a countersuit for liable.

Healthcare Patients

Medical patients are in a particularly unique spot when is comes to Medicare, Medicaid and Tricare fraud.

Overbilling, upcoding and unbundling are common in Medicare fraud cases. The first person outside medical care facilities to see this are patients.

Patients will need more than circumstantial evidence however to prove fraud.

A careful review of their Medicare statements can reveal procedures, treatments and drugs they did not receive. This is fraud and should be reported.

Medical Branch

The medical sector of the healthcare industry includes all those who directly treat patients or provide prescription drugs to them. These individuals have all received and are certified in their field to provide healthcare.

• Doctors, Surgeons, Physicians
• Nurses, Nurse-Midwife, Physician assistant
• Physical therapist
• Radiologist
• Pharmacist

This group’s knowledge and reporting of healthcare fraud varies.

As employees of healthcare facilities these professionals are sometimes not in a position to know fraudulent acts are occurring. They are typically honest people who are helping patients directly for most of the day.

For those who do have knowledge of fraud they may not report because they are worried about getting fired.

When they do report and become qui tam plaintiffs their knowledge provides for very strong cases, often leading to a settlement before trial.

They can offer evidence and testify directly to actual medical treatments that were completed and necessity of those procedures.

In qui tam cases the value of their testimony and reports of fraudulent behavior is very high. As whistleblowers their level of education, training and certification gives them an increased credibility.

In recent years these relator’s credibility and knowledge has been utilized often in pharmaceutical fraud cases.

Within the medical sector of the healthcare industry, pharmaceutical fraud takes the form of kickbacks, CME fraud, claims for off label prescription coverage and pharmacy fraud.

Most individuals working in the medical sector of the healthcare industry of good people.

When they suspect healthcare fraud is occurring the public relies on these good people to come forward and blow the whistle to help stop the illegal activity.

Sometimes it requires they expose the most common area where healthcare fraud to occurs: The Medical Administrative Division.

Administrative Division

The administrative division of the healthcare industry includes all those who manager and administrator medical care facilities. These individuals are responsible for operations, management, billing, staffing and contracting. Basically, the business side of any healthcare provider.

• Hospital Administrator
• Office Manager
• Accountant / Accounting / Bookkeeper
• Insurance Coordinator
• Vice Presidents (operations, marketing, sales, staffing, etc.)
• Manager of Medical Records
• Patient coordinators

This groups knowledge of fraud is the most common due to their position as the liaisons between the Medical and Business sectors.

When Medicare fraud is occurring one or more of these positions is aware of it. They are responsible for patient records, submission of claims and collection of payments.

Unscrupulous medical companies and bad Doctors use these individuals credentialed and notary status to make false claims for services resulting in millions of dollars of illicit gains.

The most common place for fraud to occur within the healthcare administration sector is in large corporate hospitals.

Hospital fraud can take several forms depending on how the patient was processed and how the program was billed.

Within the hospital administration sector there are three basic forms of hospital fraud; Inpatient fraud, outpatient fraud and cost report fraud.

Individuals employed in the administrative division of medicine who suspect fraud are often times in a difficult situation.

Employers can intimidate or threaten people by stating they are just as culpable in the fraud and will face charges along with them. Or they will lose their job if they report the fraudulent behavior.

The administrative division of medicine is the accounting, reporting and record keeping side of the industry. This is why fraud investigators look for wrongdoing there first.

A less common area where investigators look for fraud is the Research Branch of the healthcare industry.

Research Branch

The research branch of the healthcare industry includes all those who help discover new and improved methods for a better state of physical and psychological health. These individuals conduct research, tests and track results of regulated experiments. Essentially the improvement sector of medicine.

• Lab Technicians
• Medical Reach Scientists & Biologists
• Clinical Research Associates
• Clinical Trial Administrators & Statisticians
• Regulatory Affairs Manager

This branch of medicine is a less common place to find fraud, but it does exist and should be reported.

The motivation to discover newer, more effective treatments and drugs is normally why research scientists, medical companies and universities conduct medical research.

For this reason, the Federal Government supports the research through grants and funding.

However, some deceptive practices are used for monetary gains. When this occurs, it is a violation of the False Claims Act and whistleblower protection applies.

Common types of research fraud include misallocation of time across grants, falsification of PI verified reports and non-chargeable activities expensed to grants.

When those working in the research division are aware of fraudulent behavior, they can bring a qui-tam lawsuit for research misconduct.

The most common place for research fraud to occur is in the University system since it is where a majority of research takes place.

Scientists and companies can be motivated by more than just money. Some want notoriety for continued success in research. Ego driven factors do lead to falsification of results.

Others use different forms of payment like compensation for time inappropriately charged against unrelated grants.

Universities can be involved as well by encouraging a “spend down” of grant funds that were close to expiration.

Research fraud is here to stay and is becoming a more intensely looked at division of medicine as University budgets tighten.

Since the research branch is at the forefront of medical advancement you will typically find companies and their sales consultants there.

Sales & Consulting Branch

The sales and consulting branch of the healthcare industry is focused on providing medical facilities with the supplies, pharmaceutical products, devices, equipment and services they need to improve. These individuals work for a medical company and specialize in the sale of specific products and services.

• Medical Device & Pharmaceutical Sales Representative
• Quality Improvement Consultant
• Accreditation Consultant
• Regulatory Consultant
• Medical Service Sales
• Medical Marketing Consultant

Like the Administrative Division, this sector of the healthcare industry is another common place to find medical fraud.

The Federal Government regulated this sector of the medical industry quickly. This regulation came in the form of Anti-Kickback and Stark Laws.

These laws prohibit sales people from providing monetary commission to Doctors and Medical facilities for the sale of their medical products and prescription drugs.

The Anti-Kickback law even prohibits medical companies from providing other forms of payment like vacations, dinners and entertainment.

While the Stark law prohibits Doctors from receiving payment for referring patients to medical facility they have a monetary or other relationship which they benefit from.

Violating these laws can become a qui tam lawsuit when any portion of the payment received was from a Government program like Medicare, Medicaid or Tricare.

When this is the case whistleblower protection is provided as long as the individual reporting the fraud come forward in a timely manner.

Unfortunately, within the sales sector of medicine money is the driving force. This leads to individuals waiting too long to report fraud. At some point they become complicit in the fraud.

Sales representatives and consults are extremely helpful in the healthcare industry because they are at the forefront of new developments and products Doctors need.

In most situations the four sectors of the healthcare industry do not violate the law. They keep a check and balance of each other.