FAQs On False Claims Act Whistleblower Cases

ATTORNEY NEWSLETTER

What is a False Claims Act Whistleblower Case?

Private citizens and businesses help the government recover billions every year in cases of fraud against the government. The private citizens and businesses assisted the government in recovering these funds by bringing civil lawsuits on behalf of the government under the False Claims Act, (“FCA”), 31 U.S.C. § 3729 et seq.    The private individuals or businesses bringing the actions are known as “relators,” and the cases themselves referred to as “qui tam” cases.  If the government recovers, the relators are eligible for rewards. 31 U.S.C. § 3730(d).  Attorneys’ fees and expenses are mandatory for relators who successfully recover funds for the government.  31 U.S.C. § 3730(d)(1).  

Who are whistleblowers normally?

Whistleblowers (“relators”) of fraudulent conduct are often employees, accountants, controllers or managers, or former employees or managers, or competitors of the business engaging in the fraud.  If you have credible information of fraud against the government in violation of the FCA in San Francisco or elsewhere in California, call us today at (415)441-8669 and we can help. Our toll-free number is 1-888-50EVANS (888-503-8267).

Are Attorneys’ Fees Paid By the Wrongdoer?

Yes. Attorneys’ fees and expenses are mandatory for relators who successfully recover funds for the government.  31 U.S.C. § 3730(d)(1). 

Is there a case example?[1]

Yes.  The U.S. Department of Justice recently announced that a health care provider agreed to pay $14,100,000, to resolve allegations that it violated the False Claims Act by causing the submission of false diagnosis codes in order to increase payments that they received from the Medicare Advantage program. The settlement resolves allegations, from 2020 to 2023, the provider submitted diagnosis codes within Hierarchical Condition Code (HCC) 55 (Drug and Alcohol Dependence) and HCC 59 (Major Depressive, Bipolar, and Paranoid Disorders) that were not clinically valid, not properly supported by the beneficiary’s medical records, and/or not considered in the care, management, or treatment of the beneficiary.

The United States contends that the company disseminated incorrect coding guidance to its coders and physicians regarding diagnosis codes within HCC 55 and HCC 59. The United States further contends that company coders reviewed its beneficiaries’ medical records and identified additional diagnosis codes for chronic conditions, including diagnoses within HCC 55 and HCC 59. According to the government, the company then prompted doctors to add those diagnosis codes, even when the diagnosis codes were unsubstantiated or not clinically justified. As a result, the doctors added those diagnosis codes, which were not accurate according to the qui tam complaint. These diagnoses resulted in an increase in payment from the government over what should have been paid out for the applicable patients.

The whistleblower, a former risk management employee of the defendant company, will receive approximately $2,467,500 as her share of the federal recovery.

How Do Qui Tam Actions Work?

Any False Claims Act whistleblower case begins by a relator filing a complaint under seal in the federal court usually for the United States District Court for the district where defendant is located or does business. At the same time, the relator submits a disclosure to the DOJ outlining the material evidence the relator has of the alleged false claims. 31 U.S.C. § 3730(b). The seal period of the complaint lasts 60 days during which the DOJ investigates the claims.  31 U.S.C. § 3730(b)(2). (If necessary, the government can, and often does, extend the 60-day period during which the allegations are kept under seal.)  If the government decides to intervene in the case, the government essentially takes over the litigation. 31 U.S.C. § 3730(c)(1).   If the government declines to intervene, the relator may proceed with the litigation on his or her own.  31 U.S.C. § 3730(c)(3).

Contact Us

If you have credible information of government fraud in San Francisco or elsewhere in California, call Ingrid M. Evans at (415) 441-8669, or toll-free at 1-888-50EVANS (888-503-8267) or by email at <a href=”mailto:[email protected]”>[email protected]</a>.  In addition to FCA and CFCA whistleblower cases, Ingrid and Evans Law Firm, Inc. also handle bank fraud whistleblower cases under FIRREA/FIAFEA, commodity trading and securities fraud under the Commodities Futures Trading Commission Whistleblower Program and the Securities and Exchange Commission Whistleblower Program, and tax fraud under the Internal Revenue Service Whistleblower Program. 

[1] Evans Law Firm, Inc. was not involved in the reported case in any way.