Whistleblowers filed a Scripps Health qui tam lawsuit that ended with the company agreeing to pay $1.5 million to resolved False Claims Act allegations.

According to the Scripps Health qui tam lawsuit, the healthcare company committed fraud when billing federal healthcare programs for physical therapy services that were not submitted by proper authorities.

The settlement will resolve numerous claims of filing improper billing claims to Medicare and TRICARE for physical therapy services. The allegations state Scripps Health had sent billing claims using unenrolled doctors without the supervision of enrolled Medicare or TRICARE professionals.

The Scripps Health qui tam lawsuit was filed by former Scripps Health employee and whistleblower Suzanne F. For her role as a whistleblower, she will receive $225,000 as part of the settlement. Typically, whistleblowers can expect to receive between 15% and 30% of whatever settlement or judgment is recovered.

Overview of Scripps Health Qui Tam Lawsuit

These unenrolled doctors reportedly lacked the status and privileges to bill under the federal healthcare programs, with the Scripps Health qui tam lawsuit also alleging the claim process was not supervised by an authorized provider.

Both Medicare and TRICARE require healthcare facilities to be enrolled providers in order to be eligible for billing services. When unenrolled providers bill these programs for services it is considered “incident to” the services of an enrolled physician. However, an exception can be made if an enrolled participant supervises the process.

Scripps Health allegedly did not follow the correct process and had unenrolled doctors billing Medicare and TRICARE for physical therapy services without proper supervision. The federal government ultimately accused Scripps Health of failing to follow proper procedure when billing Medicare and TRICARE for physical therapy services by unenrolled therapists.

“Federal health care programs require that services are rendered by authorized providers or under the appropriate supervision of an enrolled physician. … These requirements help protect patients from unscrupulous or unqualified medical professionals. The Department of Justice will continue to ensure that those who knowingly violate these requirements face appropriate consequences,” said lawyers involved in the Scripps Health qui tam lawsuit.

Lawyers involved in the Scripps Health qui tam lawsuit state they are pleased with the outcome, and they hope this will highlight the government’s resolve to combat fraud. They hope more whistleblowers will come forward to report fraud, with promises of privacy protection under the False Claims Act.

Under the False Claims Act, employees or other individuals are encouraged to come forward to report fraud and help protect the money of hard working taxpayers. It is important to note that whistleblowers must be the primary source of information of the alleged fraud, and cannot get information from secondary sources.

This Scripps Health qui tam lawsuit was investigated by various federal litigation authorities including the Civil Division’s Commercial Litigation Branch, the U.S. Attorney’s Office for the Southern District of California, the Defense Health Agency Program Integrity Office, and several others.

This Scripps Health Qui Tam Lawsuit is Case No. 16-CV-0634, in the U.S. District Court for the Southern District of California.