A new Medicare and Medicaid whistleblower lawsuit alleges that an Advocate Health Care teaching facility violated the False Claims Act by billing Medicare and Medicaid for surgeries performed with assistant surgeons and physician assistants when qualified residents were available.

In the Medicare and Medicaid whistleblower lawsuit, whistleblower Luay A., a doctor who completed his medical residency the the Chicago-area hospital, says Advocate Health refused to use residents in surgeries, but then billed Medicare and Medicaid for their assistance.

Unsealed last week, the Medicare and Medicaid whistleblower lawsuit filed in Illinois federal court alleges that Advocate Health Care stated they did not have qualified assistant surgeons available for operations, even though records showed that qualified residents were in the operating room.

Specifically, the complaint says that teaching hospitals are required to use qualified residents when they are available for surgeries with Medicare and Medicaid patients.

Medicare and Medicaid reimburse teaching hospitals for some expenses, as they’re expected to have higher patient costs due to seeing more severe cases and other costs like inexperienced residents ordering extra tests.

Luay’s lawsuit references several examples of surgeries involving Medicare and Medicaid patients where qualified residents were available and not used, including one example where a physician would repeatedly use  his own daughter – a physician’s assistant – rather than available qualified residents, but that the hospital still improperly billed Medicare and Medicaid for reimbursement.

The Medicare and Medicaid whistleblower lawsuit further alleges that Advocate Health has known about the improper billings for at least a decade, noting that the past president of Advocate Christ Hospital and Medical Center  had been informed of the practices more than a decade ago.

Advocate Health also received improper graduate medical education payments from Medicare and Medicaid, according to the lawsuit.

“The conduct of defendants, as alleged herein, has not only defrauded the Medicare, Medicaid, DGME and IME programs, it has also undermined the core values and purposes of [graduate medical education] — namely, the best possible education and training of America’s future physicians,” the complaint states.

The federal government and Illinois declined to intervene in the Advocate Health Care Medicare and Medicaid whistleblower lawsuit, which was initially filed in March 2013.

Filing a Medicare and Medicaid Whistleblower Lawsuit

Fighting Medicare and Medicaid fraud can be a very tough task for the government, because it can be difficult to initially detect the fraud. By filing a Medicare and Medicaid Whistleblower lawsuit on behalf of the U.S. government, a private citizen can help the government fight fraud.

Such actions are permitted under the federal False Claims Act. The Act encourages individuals with inside knowledge of fraudulent activity to take legal action themselves on behalf of the government.

If the government joins the action and recovers illegally obtained payments – either through a settlement or trial – the whistleblower is entitled to receive between 15 percent and 25 percent of the money recovered.

Even if the government does not join the lawsuit, the whistleblower may proceed individually (although this is much less likely to be successful) and receive up to 30 percent of the amounts recovered.

Medicare and Medicaid fraud can take many forms. If you are unsure exactly what constitutes this type of fraud or if you suspect that Medicare or Medicaid fraud is being committed against the government, please contact an experience whistleblower attorney who can answer your questions and advise you of your legal options at no charge.

The Advocate Health Care Medicare and Medicaid Whistleblower Lawsuit is Case No. 1:13-cv-01826, in the U.S. District Court for the Northern District of Illinois.