When you witness misconduct in your workplace, it can be difficult to figure out whether it meets the legal definition of fraud. It is possible, unfortunately, for company policies to be unethical or inappropriate without technically being illegal.
When a company or individual intentionally requests unearned or inappropriate reimbursements from the government, they are ultimately hurting taxpayers. This is the type of fraud that leads to qui tam lawsuits: deliberate, large-scale fraud schemes that misuse state or federal funding.
Many of America’s major industries rely on taxpayer dollars to thrive. Programs like Medicare, Medicaid and TRICARE therefore have rules in place to ensure that taxpayer funding is used responsibly.
What whistleblowing means to the government
As it relates to qui tam lawsuits, fraud is a deliberate, significant misuse or theft of taxpayer funding. It can be committed by individuals or entire organizations.
For example, healthcare organizations can commit fraud by regularly encouraging employees to upcode or unbundle Medicare services, and defense contractors can do so by knowingly charging the government for faulty military equipment.
Any publicly traded company may also be guilty of fraud if it deliberately misleads investors or engages in money laundering, insider trading, or other securities violations.
Whistleblowers are individuals that give the government detailed evidence and information about such fraud schemes. Because that evidence must demonstrate an intent to defraud the government, most whistleblowers are employees or contractors of the fraudulent company.
People who work for or with the company usually have the most opportunities to collect evidence such as internal emails, invoices, and relevant patient records.
How to identify fraud
Any healthcare provider that deliberately or negligently hurts patients should of course be reported. That said, certain types of patient harm are classified as medical malpractice, not fraud.
When it comes to whistleblower laws like the False Claims Act, fraud pertains specifically to the misrepresentation of goods and services in pursuit of unearned public reimbursements.
It is possible for companies and individuals to commit both fraud and malpractice, but in order to file a whistleblower case with the government you must prove that a significant amount of state or federal funding has been misused.
The amount of defrauded funds plays an important role in the government's decisions about which cases to pursue. Though each whistleblower program has different reward policies, rewards have traditionally been offered to whistleblowers whose original information generates $1 million or more in recoveries for the government and taxpayers.
In pursuit of qui tam cases, the government therefore tends to investigate systemic fraud schemes where hundreds or even thousands of false claims have submitted.
An experienced whistleblower attorney can help you find out whether the misconduct you've witnessed qualifies as fraud.