For an example of how whistleblowers and the False Claims Act interact, read this article, Home Health Care Industry Reels from Medicare Scandal. Whistleblowers can bring qui tam lawsuits against providers and benefit hugely. In this particular case, the whistleblower benefits as follows:
The False Claims Act permits individuals to file qui tam lawsuits against companies that defraud the government. Liable companies pay as much as three times the government’s losses plus penalties for each false claim. When the government joins the case, whistleblowers are entitled to 15 percent to 25 percent of the government’s recovery.
The government, Diaz, and the defendants last year entered into a settlement agreement that led to $33,872,626.03 being repaid to the government. As a result of her whistleblower status, Diaz received 20.75 percent of that recovery. The case remained under seal during the ongoing investigation, and was unsealed last Oct. 10. (AJ)
What were the fraudulent activities that yielded such a repayment?
In her qui tam lawsuit, Diaz alleged that Perez employed “marketers” (also known as “cappers”) who recruited patients for home health services — whether the services were needed or not — and then billed Medicare for tens of millions of dollars’ worth of home health services that were never provided. Cappers were paid as much as $400 per enrolled patient, according to the lawsuit. Often patients were paid to enroll as well. Some of the patients also were cappers, getting paid to recruit other patients. The lawsuit said Perez paid kickbacks to doctors to get referrals.
Perez’s companies obtained the necessary physician certifications that home health services were required, even though the doctors generally didn’t see the patients they were certifying for the services, the lawsuit said. The doctors often made up diagnoses to qualify patients for Medicare and Medicaid, according to the lawsuit.
Patients received few, if any, visits, once they were enrolled. The companies billed Medicare and Medicaid for regular visits, falsifying documents to obtain payments. The companies also obtained many signatures from patients in advance, so they could use those signatures as needed for forms that Medicare and Medicaid periodically required.
Also, this week the defendent was sentenced to 46 months in prison and asked to pay Medicare an additional six million on top of the afore mentioned amount.
The fraud in this case appeared pretty evident, according to the prosecutor, given that the defendant’s home health business went from a start-up to one of the top agencies in California in only 18 months.
