An overbilling Medicare settlement allows a whistleblower to share in nearly $65 million in a recent false claims lawsuit.

The San Diego whistleblower will receive $17.2 million with the overbilling medicare settlement. The whistleblower was part of the false claims lawsuit filed against Alvarado Hospital in San Diego and Paradise Valley Hospital in National City among 14 other Prime Healthcare facilities, according to the Los Angeles Times.

According to the U.S. Department of Justice, Prime “engaged in a deliberate corporate-driven scheme to increase inpatient admissions of Medicare beneficiaries,” They also add that the company “engaged in up-coding by falsifying information concerning patient diagnoses.”

Up-coding involves making certain conditions seem a lot worse than they are in the hopes of increasing Medicare reimbursement.

However, the overbilling medicare settlement is not an admission of wrongdoing, the government iterates. As part of the settlement, the claims (up-coding and improper admission)  remain “allegations only” against the company, which operates a network of 45 hospitals in 14 states and an additional 15 as part of a not-for-profit Prime Healthcare Foundation.

However, according to Prime, it “determined that was in the best interest of its patients, independent physicians and employees to resolve this matter despite not agreeing that there was any truth to the allegations related to coding.”

Whistleblower and registered nurse Karin B. first initiated the false claims case as Alavardo Hospital’s former director of performance improvement by contacting the government in 2011. The nurse offered information that later turned the case into a false claims lawsuit in 2013.

During the drawn-out investigation, Karin fell ill, and according to a statement released by her legal representatives, she underwent multiple surgeries and hospital admittances.

At a point during the investigation, she even wore a hidden microphone to “secure evidence of Prime founder and CEO Dr. Prem Reddy,” the Los Angeles Times states. She also helped supply “detailed documents to support her case,” leading to her testifying for more than 12 hours at deposition.

Filing a Whistleblower Lawsuit Under the False Claims Act

The False Claims Act is a federal statute that allows private citizens who discover unlawful acts to receive up to 30 percent of money the federal government recovers. Any private citizen may sue a business or individual under the False Claims Act if that business or person is committing government fraud.

Whistleblowers play an important role when it comes to exposing unlawful activity and fraud against the United States government. Whistleblower protection was added to the False Claims Act in 1986 to prevent employers from retaliating against employees and prevent them from speaking up when necessary.

The whistleblower, in return, can then recover funds on the government’s behalf. When filing a false claims lawsuit, the company is often under wraps or seal. This means that the lawsuit is kept hidden from everyone, even those who are being investigated.

Until the Department of Justice (DOJ) begins covering the investigation, the government will investigate the allegations with the assistance of the whistleblower’s attorney or legal representatives. However, only a small number of cases actually result in the federal government taking over.

If the government does not intervene, whistleblowers are still able to continue the investigations and purse lawsuits filed under the False Claims Act on their own.