TYPICAL CLAIMS UNDER THE WRPA
- General Claims
- Claims Against City, County and other Local Governments
- Claims Against Providers of Medical Services, Supplies or Equipment
- Sales of Ordinary Goods or Services to any Agency of The State
- Claims Against Colleges and Universities
- Claims Against Government Contractors
Virtually anyone who receives money from the State or pays money to the State, can engage in conduct which would give rise to a WRPA violation. Activities which constitute a violation under the Act include, but are not limited to:
(a) knowingly presenting, or causing to be presented, to the State a false or fraudulent claim for payment;
(b) knowingly using, or causing to be used, a false record or statement to get a claim paid by the State;
(c) conspiring with others to get a false or fraudulent claim paid by the State;
(d) knowingly using, or causing to be used, a false record or statement to conceal, avoid or decrease an obligation to pay money or transmit money to the State.
Claims Against City, County and other Local Governments
Because they are recipients of large amounts of government money, local governments and officials can be defendants in WRPA actions. The most typical claims against local governments are as follows:
A. Funding Procurement Fraud
When an official or local government provides false information or data to the State in applying for any grant or to obtain any funding, or to secure an increase in any such funding.
When an official or local government fails to disclose material information or data to the State in applying for any grant or to obtain any funding, or to secure an increase in any such funding.
B. Misappropriation
When an official or local government uses funds received from the State for any purposes other than the specific purpose for which such funds had been given to them by the State.
C. Noncompliance with Grant or Funding Guidelines
When an official or local government fails to comply with the restrictions which govern the permitted use, method and manner of expending monies they have received from the State.
D. Evasion
When an official or local government provides false information or data to the State to reduce or eliminate any required program contribution or the payment of any sums which might otherwise be due and owing to the State.
When an official or local government fails to disclose material information or data to the State to reduce or eliminate any required program contribution or the payment of any sums which might otherwise be due and owingto the State.
E. Retention of Overpayments
When an official or local government receives an overpayment of State funds, or realizes a surplus from such funds received, due to an expense being less than previously anticipated, and the official or local government fails to report the overpayment or excess to the State.
Claims Against Providers of Medical Services, Supplies or Equipment
A substantial portion of the monies recovered under the WRPA, involve cases against Doctors, Hospitals, Clinics and companies or entities which were engaged in the practice of providing medical services, medical supplies and/or medical equipment.
All too often such entities and individuals receive monies from Medicare, Medicaid, or any medical insurance which is funded in whole or in part, by the State. This gives rise to a wide variety of qui tam violations, the most typical of which are as follows:
Billing for Brand - Billing for brand name drugs when generic drugs are actually provided.
Bundling - Billing more for a panel of tests when a single test was asked for.
Concealment - Failing to disclose, or taking affirmative acts to conceal billing errors which resulted in overpayment for services or goods provided.
Double Billing - Charging more than once for the same goods or service.
Equipment Billing Fraud - Billing for the use of new equipment, or premium equipment, when either used or inferior equipment is provided.
Inflated Management Fees - Artificially inflating management fees in situations where the government pays management fees in connection with any provision of medical services, or in the conduct of government-sponsored medical research.
Kickback Fraud - Prescribing a medicine or recommending a type of treatment or diagnosis regimen in order to win kickbacks from hospitals, labs or pharmaceutical companies.
“Lick & Stick” - Prescription rebate fraud and “marketing the spread” prescription fraud both of which involve lying to the State about the true wholesale price of prescriptions.
Phantom Billing - Billing for tests, goods and services that were never delivered or rendered.
Phantom Labor - Charging for employees that were not actually on the job, or billing for made-up hours to maximize reimbursements.
Retention of Overpayments - Being overpaid by the State for a service or good, and then not reporting the overpayment to the State.
Shelling - Setting up a shell company, or manipulating the mode or receiving payments for the purpose of inflating the rate of reimbursement to be received.
Shorting - Charging for full quantities of prescriptions, when actually dispensing partial or short prescriptions.
Signature Fraud - Forging physician’s signatures when such signatures are required for reimbursement from Medicare or Medicaid.
Unapproved Billing - Filing claims for reimbursement of expenses and for services while knowing that such reimbursements and services were not covered by medicaid or medicare. Billing for unlicensed or unapproved drugs or devices.
Unbundling - Using multiple billing codes instead of one billing code for a drug panel test in order to increase remuneration.
Unwarranted Billings - Billing for services which were not reasonable or necessary, in frequency, duration, or at all. Billing for medically unnecessary tests. Automatically running a lab test whenever the results of some other test fall within a certain range, even though the second test was not specifically requested.
Upcoding Diagnoses - Inflating bills by using diagnosis billing codes that suggest a more expensive illness or treatment.
Upcoding Employee Work - Billing at doctor rates for work that was actually performed by a nurse or resident intern.
Upcoding Services/Goods - Billing for a more highly reimbursed service or product than the one provided.
Sales of Ordinary Goods or Services to any Agency of The State
Virtually any individual or company which sells ordinary goods, merchandise or services to any branch or office of the State, may violate the WRPA. Some typical claims which have been filed against commonly known retailers are as follows:
Failing to provide accurate pricing information in sales to the State.
Failure to pass sales discounts on to the State.
Retention of overpayments received from the State, and a failure to report such overpayment to the State.
Overcharging the State for labor or services provided.
Sales of defective goods to the State.
Claims Against Colleges and Universities
Data Falsification - Falsifying research data that was paid for by the State.
Fraudulent Billing - The employ of fraudulent billing practices at University clinics and programs to obtain unearned medicaid funding.
Grant Noncompliance - When a College or University fails to comply with the restrictions which govern the permitted use, method and manner of expending monies they have received from the State.
Misappropriation - When a College or University uses funds received from the State for any purposes other than the specific purpose for which such funds had been given to them by the State.
Phantom Research - Charging the State for research that was never conducted.
Retention of Overpayments - When a College or University receives an overpayment of State funds, or realizes a surplus from State funds received, due to an expense being less than previously anticipated, and the official or local government fails to report the overpayment or excess to the State.
Claims Against Government Contractors
Defective Goods - Selling defective goods to the State. Selling the State used equipment as new equipment. Presenting broken or untested equipment as operational and tested.
False Certifications - Providing false certification that a product meets specifications required by the State. Providing false certification that products being supplied are being subjected to testing procedures in accord with State requirements, when such testing had not been performed. Providing false certification that minority or female contractors are providing services, or are the true principals of the company or companies providing services.
False Testing - Submitting false service records or samples to show better than actual performance.
Mischarging - Charging the State for labor or services not provided, or “mischarging time” expended on other matters. Billing for marketing, lobbying or other non-contract related activities.
Nondisclosures - Failing to offer the same sales discounts to the State that sellers offer to private purchasers.
Procurement Fraud - Providing false information to secure, or in securing contracts from the State. Failing to provide accurate pricing information in sales to the State.
Retention of Overpayments - Being overpaid by the State for a service or good, and then not reporting the overpayment to the State.
To read about actual cases, go to the NEWS section of this web site.