In the past 20 years, health care whistleblowers have helped the United States recover more than $20 billion lost by the government to fraud. For their efforts, doctors, nurses, pharmacists, sales reps and other medical professionals have been paid more than $3 billion by the Department of Justice. However, there is still much more work to be done. Medicare fraud is estimated at around $60 billion every year.
Nurses have witnessed and reported a number of illegal acts by doctors, hospitals, nursing homes and home health agencies. On the front lines of treating patients, these individuals will often be exposed to questionable billing practices, inadequate patient care and other violations of the False Claims Act.
Pharmacists have been responsible for stopping a wide variety of misconduct in the medical profession. They have turned in their employers, competitor pharmacies and drug companies for misconduct. They have access to a great deal of information about medical providers, drug sales and insurance providers. One of the most successful pharmacy companies turned whistleblower was Florida’s Ven-A-Care, which earned more than $500 million reporting pharma fraud and other illegal acts.
Big pharma sales reps have frequently turned in pharmaceutical companies for illegal marketing practices. The three largest settlements under the False Claims Act (GlaxoSmithKline, Johnson & Johnson and Pfizer) included reports to the Department of Justice about the practices from individuals involved in drug sales at the three companies. Sales reps have access to key information necessary for the government to prove marketing tactics of these companies when they are asked to engage in off-label marketing or kickbacks to physicians,
Compliance Professionals & Consultants
As hospitals, insurance companies and other entities in the health care industry examine their data for fraud and potential legal violations, some of their employees and consultants will detect problems. If the company does not respond appropriately to their internal reports, the False Claims Act offers a mechanism to report the fraud externally to the government.