QUI TAM INVESTIGATIONS AND LITIGATION

In theory, any health care provider who has employees is in danger of a qui tam action. In reality, any health care provider who has employees is in danger of a qui tam action.

Qui tams are a poison pill for any health care provider, particularly larger institutions that are reimbursed by public funds.  The amount of damages that result from these actions can be catastrophic.

KEY DEVELOPMENTS

•    The Federal False Claims Act, providing a means for private citizens to act as bounty hunters for violators of this act through the use of qui tam actions, has been in effect for over 100 years.  Now, many states, such as New York, are  armed with their own False Claims Acts (FCAs), modeled on the Federal FCA, which contain qui tam provisions that are designed specifically to increase recoveries and insure strict compliance.  

•    Because of the intensified scrutiny on health care providers who receive public funds, regulators are encouraging greater use of qui tams as an effective tool to improve recoveries, and the number of qui tam actions will escalate  substantially.  

HOW DAYLIGHT CAN HELP

    Qui tam suits start from within, and are grounded in some deficiency in the program itself or a failure to follow the existing protocol.   Members of Daylight’s compliance team understand how and why qui tams begin, can identify high risk areas, and devise and monitor compliance programs with this in mind to insure that the compliance program is both effective and comprehensive.

    It is also imperative to insure that a provider’s compliance program has an effective reporting system to alert management of a potential problem as soon as possible before the possibility of a qui tam action.   A provider’s initial response and corrective action is of great importance to the ultimate disposition of the suit.  Our team consists of health care defense attorneys and former prosecutors who have litigated qui tam suits, medical review specialists (including certified coders) cost report auditors, and statisticians who can assist in investigating the merits of the allegations as quickly and accurately as possible.   Should an investigation turn into litigation, Daylight’s health care litigation support services can assist in all phases of litigation requirements.

DAYLIGHT HEALTHCARE QUI TAM SERVICES INCLUDE:

•    Develop a compliance program or procedures to insure timely and appropriate reporting, corrective action plan and investigative protocol.

•    Work with outside counsel in providing expertise through all phases of the qui tam investigative process
    
•    Analysis by medical review specialists specific to the qui tam allegation.
 
•    Analysis by auditors specializing in health care regarding billing and cost report issues

•    Statisticians specializing in health care billing databases to conduct statistically-based sampling. Review and analysis of electronic data relevant to qui tam investigation