Who Files a Claim?
San Antonio Whistleblower Cases
The person bringing the lawsuit through his or her attorney is called the “relator,” commonly known as the Whistleblower. To bring the lawsuit the relator must allege with specificity and clarity that the defendant:
- knowingly presented or caused to be presented a false or fraudulent claim for payment or approval to an officer or employee of the United States government;
- knowingly made, used, or caused to be made or used, a false record or statement to get a false or fraudulent claim paid by the government, conspired to defraud the government by getting a false or fraudulent claim allowed or paid; or
- knowingly made, used, or caused to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the government, (known as a reverse false claim).
What types of Fraudulent Conduct does the False Claims Act Include?
The range of fraudulent activities that have been prosecuted under the False Claims Act is expansive and includes, but is not limited to, the following:
Contractor Fraud: Winning a contract through kickbacks or bribes.
Defense Industry Fraud: Supplying guidance systems that do not guide; supplying faulty weaponry, supplying faulty equipment that does not operate in the field.
Environmental Fraud: Extracting resources, such as oil, timber, and minerals from public lands without paying for that right.
Grant Fraud: Misuse of grant funds and making false statements in grant applications to obtain funding.
Mischarging: Billing for goods or services that were never delivered or rendered. For example, charging employee labor to a government contract even though the employee did not work on the contract, or making claims to the government for medical services that were not rendered.
False Negotiating & Defective Pricing: Involve submission of false cost and pricing data to the government during the negotiation of a contract in order to obtain an inflated contract price.
Product and Service Substitution: Providing an inferior product and then falsely certifying that the product met specifications or that reliability testing was performed.
Healthcare, Medicare and Medicaid Fraud: Healthcare fraud cases can involve various activities, such as: falsely certified medical necessity determinations; physician identifier numbers being misused to bill Medicare or Medicaid; mischarging Medicare or Medicaid for the cost of experimental devices; mislabeling unapproved medical devices in order to obtain Medicare or Medicaid reimbursement; billing for tests not performed; performance of inappropriate, unnecessary, and/or duplicative procedures; billing for equipment or supplies never ordered; billing for new or expensive equipment but providing the patient used or inexpensive equipment; completion of a Certificate of Medical Necessity by a drug or equipment supplier instead of the physician; using false diagnosis codes to get Medicare or Medicaid coverage; double billing which is charging more than once or the same service; bundling which is billing more for a panel of tests when a single test was asked for; unbundling which is using multiple billing codes instead of one billing code for a drug panel test in order to increase payment; upcoding which is inflating bills by using diagnosis billing codes that suggest a more expensive illness or treatment; billing at doctor rates for work that was actually conducted by a nurse or resident intern; prescribing a medicine or recommending a type of treatment or diagnosis regimen in order to win kickbacks from hospitals, labs or pharmaceutical companies; Billing for unlicensed or unapproved drugs; and Forging physician signatures when such signatures are required for reimbursement from Medicare or Medicaid.
The False Claims Act does not include, tax fraud, trust fraud, inheritance fraud, or estate fraud.
Rosie Alvarado, P.C.
San Antonio, Texas 78205