The Department of Justice (DOJ) for the Eastern District of California announced on July 7 that Wal-Mart Stores, Inc. (Walmart) paid $1.65 million to resolve accusations related to unlawful medical claims. This is an important suit as it demonstrates that the federal and state governments will go after large retailers for false claims. Pursuing whistleblower suits and securing government funds that were unlawfully obtained remains a top property for the DOJ.
Walmart’s False Claims
Through a qui tam suit brought by a former Walmart pharmacist in the Sacramento area, the California government learned that Walmart was allegedly submitting false claims to the state’s Medi-Cal program in order to increase reimbursements. Supposedly, Walmart would knowingly submit claims that were not supported by a proper and relevant diagnosis or documentation. More specifically, Walmart would submit reimbursement claims for Code 1 drugs that were not based on proper and pre-approved diagnoses. Medi-Cal only reimburses for Code 1 drugs if they were prescribed for approved diagnoses. If a Walmart pharmacy wanted reimbursement for a Code 1 drug for something else, it would need to submit a specific request with the reasoning for a non-approved use. Walmart pharmacists intentionally submitted claims without confirming the approved diagnosis and obtaining the necessary documentation or for non-approved uses.
What is a Qui Tam Suit?
A qui tam lawsuit, also known as a whistleblower action, occurs when a private citizen has information regarding false claims or invoices made to a state or the federal government in order to unlawfully receive or retain money. The private citizen, having this information, files a lawsuit on the government’s behalf. Once the suit is filed, the citizen becomes known as the relator. He or she is a party to the case and stands in for the government while the state or federal government investigates the claims and decides whether or not to join. If the government joins the case against the defendant, it becomes an official party. If the government does not decide to join the case, it is up to the relator whether to move forward without the government’s assistance or to dismiss the case.
If the government, whether or not it joins, ends up coming to a settlement agreement with the defendant or wins a judgment at trial, then the relator financially benefits. If the government recovers money, the relator can receive 15 to 25% of the funds.
In the Walmart case described above, the whistleblower is set to receive about $264,000.
Do You Have Information About Healthcare Fraud?
If you believe you have information about your employer unlawfully billing Medicare, Medicaid, or a state insurance program, call Brod Law Firm at (800) 427-7020. During a free consultation, we can discuss your potential evidence and whether a qui tam lawsuit may be possible. Qui tam lawsuits can be time-consuming and difficult. However, if you have strong evidence of fraud, you can be richly rewarded for coming forward on the government’s behalf.
(image courtesy of Andres de Armas)