Every day, hospitals charge patients, insurance companies, and federal agencies millions of dollars for the medical services they provide. The astounding volume of healthcare charges presents opportunities for corrupt facilities to defraud federal payers.
According to the National Health Care Anti-Fraud Association (NHCAA), healthcare fraud costs taxpayers roughly 3 to 10 percent of total annual healthcare expenditures in the U.S. – or up to $300 billion per year.
If you have information about possible hospital fraud at a Denver area hospital or another facility in Colorado, contact The Wilhite Law Firm for a completely confidential and free consultation with our healthcare fraud attorneys. You could be entitled to recover money as a whistleblower in a qui tam lawsuit.
What Is Hospital Fraud?
Hospital fraud occurs when hospitals, urgent care clinics, and other healthcare facilities submit improper billing information to obtain inappropriate funds from federal healthcare programs like Medicare, Medicaid, and TRICARE. Fraudulent hospitals engage in various underhanded practices to increase their profits at the expense of American taxpayers and patients. Medicare and Medicaid fraud and other forms of health care fraud wrongfully divert billions of dollars to healthcare providers across the country despite federal laws intended to thwart the practice.
In the United States, hospital fraud is typically considered a violation of the federal False Claims Act. Abraham Lincoln signed the False Claims Act (FCA) into law during the Civil War to combat unethical profiteering and exploitation. Congress has updated it multiple times since then.
Under the FCA, citizens can file lawsuits against fraudulent hospitals and healthcare facilities on behalf of the federal government. A citizen’s ability to file such a lawsuit comes from a “qui tam” provision in the FCA that allows citizens to act as “relators” who sue in the government’s interest. The provision encourages relators to act as whistleblowers by providing monetary incentives to those who recover public funds.
What Are Common Types of Fraud in Healthcare in Denver, Colorado?
The term “healthcare fraud” applies to a wide range of unlawful practices by hospitals, health care providers, and facilities aimed at claiming more money than hospitals deserve for their services. Common types of hospital fraud include:
- Billing for services that were not provided – This type of false record fraud occurs when hospitals and healthcare professionals bill payers for diagnostic tests, treatments, and other services that patients did not receive.
- Billing for unnecessary procedures – Hospitals can defraud the government by billing for medically unnecessary procedures, which are not eligible for reimbursement from federal programs.
- Unbundling, inflating costs, or double-billing – Federal payers require certain services to be bundled together for billing purposes. “Unbundling” refers to the unlawful practice of billing individually for these services. Some hospitals may also improperly inflate the billed costs for certain services or “double-bill” by seeking reimbursement for the same services from multiple payers.
- Misrepresenting patient data by “upcoding” – The process of “upcoding” involves billing payers for more than a hospital’s services are worth by submitting improper codes that apply to more expensive services than those provided.
- Providing kickbacks to physicians – This involves the illegal practice of paying or bribing physicians or other providers who refer patients to the hospital.
Who Could Be a Hospital Fraud Whistleblower?
One of the most challenging aspects of prosecuting healthcare fraud involves recognizing when it occurs in the first place. Because medical terminology is so highly specialized, it typically takes a trained professional from the medical field to understand it. As a result, it’s relatively simple for hospitals to submit falsified billing information by hiding it beneath a layer of industry jargon.
Unscrupulous hospital administrators frequently misrepresent certain services as more costly or necessary by relying on terminology that is essentially foreign to anyone without a medical background. Consequently, most whistleblowers in healthcare fraud cases are hospital employees who can understand the jargon and recognize when something isn’t right.
However, many potential whistleblowers are hesitant to speak out due to fears of retaliation in the workplace. While it’s understandable to be concerned about losing your job or facing other repercussions from an employer, the False Claims Act protects whistleblowers from this type of discrimination when they make reports or file qui tam lawsuits. In some cases, you can even receive compensation if you endure harassment or other retaliation as a whistleblower.
What Compensation Is Available for a Denver Hospital Fraud Case?
Under the qui tam provision of the FCA, whistleblowers in hospital fraud cases may be entitled to compensation from subsequent lawsuits. The federal law also contains a “First to File Rule” that restricts the ability to obtain compensation in qui tam actions to the first whistleblower who comes forward with information about the alleged fraud. The amount of compensation that may be available in a qui tam case depends on several factors, including:
- The overall value of the case – Qui tam whistleblowers may receive a percentage of the overall funds recovered in a hospital fraud case, typically ranging from 15 to 30 percent. The greater the magnitude of fraud reported, the more money there is to be recovered and the more compensation available for a whistleblower.
- The type of information provided – If a whistleblower provides more valuable evidence and information about the fraud, they are more likely to receive a higher percentage of the total compensation recovered.
- Who resolves the issue – If a whistleblower provides actionable information and the government intervenes and uses it to resolve the issue, the whistleblower may be entitled to between 15 and 25 percent of the recovered money. If the government declines to intervene and a whistleblower reports fraudulent activity and pursues a private party qui tam action on their own, they could receive as much as 30 percent of the total funds.
Can an Employer Retaliate Against a Hospital Whistleblower?
Healthcare facilities are legally prohibited from retaliating against whistleblowers who report fraud under the False Claims Act. However, the law is not always enough to discourage hospitals from taking illegal actions to get back at whistleblower employees. Thankfully, employees may be entitled to seek compensation or even reinstatement in response to such retaliation.
At The Wilhite Law Firm, we can provide legal representation and support you as you navigate the process of filing a whistleblower complaint and help you understand the protections afforded to you by law.
Contact Our Denver Hospital Fraud Attorneys for Help Today
Acting as a whistleblower on behalf of the federal government can be daunting, especially if you are concerned that your job could be on the line. However, it’s important to report suspected fraud to protect the integrity of our healthcare system. You also stand to recover a significant reward for your efforts.
Contact a hospital fraud lawyer in Denver at The Wilhite Law Firm today for legal advice and learn more about how we can protect your rights as a whistleblower in a free and completely confidential consultation. We serve clients throughout the Denver area, including Arapahoe County, Jefferson County, Adams County, Douglas County, and beyond.
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