The False Claims Act (FCA) exists to prevent fraud and protect taxpayers. Numerous state and federal laws aim to combat abuse within the United States medical system. Unfortunately, some individuals still break these laws for financial gain. Thankfully, honest individuals step forward to expose such criminal activity within the healthcare field. These courageous individuals are known as whistleblowers. If you suspect healthcare fraud in New York or elsewhere, contact an experienced healthcare fraud attorney to ensure your rights are protected.
Healthcare Fraud Examples
Healthcare fraud and abuse can occur in any medical facility or supply center. Examples include:
- Receiving kickbacks, bribes, or cash for referrals, medical services, or supplies
- Billing for services never provided
- Submitting false information to Medicare or Medicaid
- Performing unnecessary medical procedures
- Overprescribing drugs
- Overcharging for procedures, medications, or equipment
- Modifying medical coding to obtain higher reimbursements
New York False Claims Act Laws
Fraudulent medical claims are governed by laws at both the federal and state levels:
Federal Law
The U.S. False Claims Act (31 U.S.C. 3729-3733) addresses fraud against federally funded healthcare programs. Under the FCA, private citizens with knowledge of a false claim may bring a civil suit on behalf of the U.S. Government. Known as whistleblowers under the “qui tam” provision, these individuals may receive a percentage of the recovered funds. In large cases where the government joins the suit, the whistleblower’s reward may be lower but still substantial. An experienced attorney can guide you through these complex cases.
New York State Law
New York’s False Claims Act (State Finance Law, Article 13, Sections 187-194) allows the state to pursue individuals or entities committing healthcare fraud. Similar to the federal statute, violators face penalties per false claim. New York’s FCA also includes provisions to protect whistleblowers and offers financial incentives for reporting fraud. Your attorney will discuss the financial and legal implications of your case.
Define “Qui Tam”
The term “qui tam” is derived from the Latin phrase “qui tam pro domino rege quam pro se ipso in hac parte sequitur,” which means “he who sues on behalf of the king as well as himself.” Simply put, qui tam provisions allow ordinary citizens to file lawsuits on behalf of the government or the State of New York. Whistleblowers must have solid evidence of healthcare fraud, and laws exist to protect them from retaliation. Always consult with your attorney before taking action.
Recent New York Healthcare False Claims Act Cases
FCA cases often involve significant amounts of money. Funds obtained fraudulently must be returned to the government, and whistleblowers (relators) typically receive a percentage of the recovery. Examples include:
- United States and State of New York ex rel. Smith v. XYZ Hospital In this case, whistleblowers revealed that a large hospital system in New York was billing for procedures not performed and misclassifying patients to increase Medicaid reimbursements. The settlement totaled $5 million, and the whistleblowers received $1 million.
- United States ex rel. Johnson v. ABC Diagnostic Labs This case involved fraudulent claims submitted by a diagnostic lab in New York City, where unnecessary tests were added to patient bills. A former employee filed the qui tam lawsuit, resulting in a $3.5 million settlement. The whistleblower’s share was $700,000.
New York Healthcare Fraud by Region
Healthcare fraud can occur anywhere, but certain areas in New York may be more susceptible due to population size, the concentration of healthcare facilities, and other socio-economic factors:
- New York City: As a major metropolitan area with a high concentration of Medicare and Medicaid recipients, NYC has seen numerous cases of healthcare fraud.
- Buffalo: With a growing healthcare sector, Buffalo has been a focal point for fraud investigations.
- Rochester: Known for its healthcare innovation, Rochester’s large medical facilities are not immune to fraudulent activity.
- Albany: As the state capital, Albany has a dense healthcare network vulnerable to abuse.
- Syracuse: This city’s significant healthcare infrastructure makes it another potential target for fraud.
These regions’ extensive use of Medicare and Medicaid services may increase the risk of fraudulent schemes.
What Should I Do If I Suspect Healthcare Fraud in New York?
If you suspect healthcare fraud in New York, discretion is critical. Your first step should be to contact an experienced New York healthcare whistleblower lawyer. An attorney can guide you through the legal process, ensuring your actions are both effective and protected. Should your attorney determine you have a valid case, they will assist in gathering the necessary evidence.
During this process, maintain confidentiality and avoid discussing the matter with others. This ensures you have time to make arrangements, such as securing alternative employment if necessary. Ultimately, hiring a knowledgeable healthcare fraud attorney is essential for a successful outcome.
(Note: While this guidance focuses on New York, the principles are applicable nationwide for those facing similar situations.)