False Claims Acts and Unauthorized Laboratory Tests

Our whistleblower lawyer blog attorneys have written extensively about Georgia’s enactment of the new State False Medicaid Claims Act, a new whistleblower law that an attorney with our law firm helped enact. This qui tam whistleblower law has applicability to anyone who files a false or fraudulent claim for reimbursement with the State’s Medicaid program.

A classic example of this would be filing false claims for reimbursement for unnecessary and/or unauthorized laboratory tests. If a health care provider submits false or fraudulent claims for reimbursement under the State Medicaid program for performing lab tests which are not properly authorized by a medical physician, or do not otherwise meet Medicaid standards for reimbursement, such a submission could constitute a false claim against the Medicaid program, thus entitling any whistleblower reporting that claim to a reward for reporting Medicaid fraud. One such case, recently filed by the State of Massachusetts, indicates just how expensive such claims may be for the taxpayer.

Last week, in Boston, Boston Clinical Laboratories, Inc. was alleged to have submitted 66,000 false Medicaid claims for urine drug screens in circumstances where they were not ordered by an authorized prescriber or were ordered for non-medical purposes. According to allegations made by the Massachusetts Attorney General, many of these laboratory urine screens were to monitor sobriety tests for the individuals and were not approved for medical reasons. Under state regulations, eligible Medicaid claims are limited to laboratory services prescribed by a physician and must serve a medically necessary purpose. Court ordered and Social Service Agency drug testing, as well as testing for resident sobriety in out-patient treatment facilities, are not covered under the Medicaid program.

While we do not know whether the allegations against Boston Clinical Laboratories, Inc. are true, the fact remains that the case indicates just how expensive unauthorized laboratory tests could be for taxpayers. If laboratories are submitting false claims for reimbursement under the State Medicaid program and if the claims being submitted are not properly approved or authorized, this could constitute a claim under the applicable State False Claims Act for which a whistleblower/informant could receive a reward.

Procedurally, a False Medicaid Claims Act Complaint alleging Medicaid fraud must be filed under seal. The State Attorney General is then given adequate opportunity to investigate the case to determine whether the State wishes to intervene in the lawsuit and take it over as a case that the Attorney General will prosecute. If the State intervenes, the whistleblower is still entitled to a recovery out of any eventual settlement or judgment obtained. In those cases in which the State does not intervene, the whistleblower and his or her counsel can proceed nonetheless in the name of the State and receive an even greater percentage of any recovery assuming fraud is demonstrated. In any event, obviously, fraud needs to be exposed in whatever form it takes.

The claims filed against Boston Clinical Laboratories, Inc. represent merely one type of claim that can be pursued under a State’s False Claims Act. Because Medicaid fraud is such a national problem one must consider just how significant false laboratory claim are in reality. The problem could be huge particularly if only one provider can submit 66,000 claims just for urine screens!