How Lawyers Investigate Whistleblower Allegations in Healthcare Fraud Cases

How Lawyers Investigate Whistleblower Allegations in Healthcare Fraud Cases

When a whistleblower comes forward with an allegation of healthcare fraud, lawyers have to jump into action to investigate the claims. This can be a complex process, but it’s important for getting to the bottom of whether fraud actually occured. Here’s an inside look at how lawyers go about looking into whistleblower allegations in healthcare fraud cases.

Interviewing the Whistleblower

The first step is usually to sit down with the whistleblower and conduct an extensive interview. The lawyer will want to understand as much as possible about the whistleblower’s background, their role in the company, and the specific details about the alleged fraud. It’s important that the whistleblower provide as much evidence as possible to back up their claims – documents, emails, recordings, or notes. The more concrete evidence the better. But even if they don’t have hard evidence, their inside knowledge of the company’s practices can still provide critical clues for where to look.

In the interview, the lawyer will also try to figure out the whistleblower’s motivations and credibility. Are they coming forward for ethical reasons? Or could they have an axe to grind with the company? This can help the lawyer determine if the allegations seem legitimate and worth pursuing further.

Researching the Company

After meeting with the whistleblower, the next step is to start digging into the company itself. The lawyer will scour any public records and statements by the company to look for red flags or hints of improper practices. For healthcare companies, lawyers may look for things like:

• Unusually high reimbursement rates or spikes in billing
• Improper incentives given to doctors or patients
• Complaints or investigations about billing, marketing, or services
• Shady relationships with contractors or suppliers

Online reviews, social media, and press coverage about the company can also provide clues. The lawyer is trying to see if the whistleblower’s allegations seem plausible based on what’s known about the company’s public track record.

Requesting More Documents

At some point in the investigation, the lawyer will likely make formal document requests to the company. This could include things like:

• Billing and payment records
• Patient medical charts
• Contracts with vendors
• Emails and correspondence
• Marketing materials

The company may try to resist handing over documents. But the lawyer can negotiate firmly or get a subpeona to compel production. Sifting through these materials is critical for finding hard evidence of fraud.

Interviewing More Witnesses

As the investigation expands, the lawyer may identify other employees who may have knowledge of the alleged fraud. Interviewing additional witnesses can help corroborate the whistleblower’s account or provide additional details. The lawyer will use discretion to determine which witnesses are worth pursuing based on their potential involvement or insights.

Undercover Investigations

In some cases, lawyers might conduct undercover investigations to gather more evidence of fraud. For example, they may send investigators to pose as patients to see if they are given inappropriate medical care or billed improperly. Or they may have someone pose as a sales rep to see if a company pays kickbacks. While risky, undercover work can sometimes produce slam-dunk evidence.

Consulting Experts

Healthcare billing and regulatory compliance is complex. Lawyers often consult medical billing experts, forensic accountants, or former regulators to provide analysis of documents and determine if fraud appears to have occured. Their expertise can be invaluable in deciphering evidence and strengthening the case.

Attempting Settlement

Before formally filing a whistleblower lawsuit, the lawyer will usually approach the company to see if they are willing to try to settle. This can avoid a long legal battle. If the evidence seems strong, the company may be motivated to settle, especially if the alternative is a costly public trial. But some companies will refuse to settle out of principle.

Filing the Lawsuit

If settlement talks fail, the whistleblower’s lawyer will prepare and file a formal lawsuit alleging healthcare fraud by the company. This initiates legal proceedings, which can include more evidence gathering, witness interviews, depositions, and ultimately a trial. But many cases settle before reaching trial. Filing the lawsuit is the big hammer that often brings defendants to the table.

Patience is Key

It’s important to understand that investigating whistleblower allegations is a long, winding road that requires patience. These cases take years to unravel, especially if the fraud is complex. Lawyers need to be meticulous in gathering evidence and building an airtight case. It’s challenging but critical work to hold companies accountable for healthcare fraud.

So if you’re a whistleblower with an allegation of healthcare fraud, know that the lawyers will need time to dig deep into the company’s practices. But you’re doing a public service by coming forward. With diligence and hard work, the lawyers can assemble a convincing case to right these wrongs.