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QUI TAM FOLLOWING UNSEALING OF THE COMPLAINT
- relator can work with government
- government can limit involvement
- assisting the government may increase the amount recovered for the government and the relator
U.S. RECOVERIES IN QUI TAM CASES
- 1988: 60 qui tam cases filed; total recovery $390,431
- 1995: 277 cases filed; total recovery $247,276,827
- 2003: 326 cases filed; total recovery $1,480,386,425
- total recovery since 1986: $7,873,273,039
NURSING HOME RELATORS
- former managers
- medical directors
- nursing directors
- treating physician
- often the nursing home resident is unable to be a relator due to disability or infirmity
HOW DO WE PREVENT FRAUD AND ABUSE
- government crackdowns
- special fraud alerts
- keying in on areas of abuse such as dme and unnecessary therapy
- alerts on inadequate patient care
SPECIFIC CASES
- a nursing home in massachusetts paid back $660,000.00 to settle allegations that it fraudulently billed medicaid for skilled nursing services it didn’t provide
OTHER EXAMPLES OF QUI TAM CASES
- stark laws-prohibits physician self referral
- recruitment of physicians
- pharmaceutical fraud
- commercial insurance fraud
STARK LAWS-PROHIBITS PHYSICIAN SELF REFERRAL
- applies to physician or family member who provides designated health services (DHS)
- very few exceptions, one of which is medically underserved areas
- generally became effective in 1995. Started with abuse of clinical laboratory services
STARK LAW DHS
- home health
- DME
- S.T., P.T., O.T.
- outpatient drugs
- inpatient and outpatient hospital services
RECRUITMENT OF PHYSICIANS
- relates to stark laws
- reimbursement must not be based on volume of patients seen
- contract must be signed by both physician and payor
- reasonable retention bonuses acceptable in underserved areas
PHARMACEUTICAL FRAUD
- 2001-2004: pharmaceutical companies have paid in excess of $1.6 billion to federal and state governments in civil false claim acts (FCA)
- in the 1960’s the typical whistleblower was a lineworker
- today the typical whistleblower is in the boardroom
- all of the seven cases settled from 2001-2004 arose from whistleblower suits by executives of the defendant companies, their competitors, or customers
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Flores Law News 
