Charleston Healthcare Fraud Attorney

The healthcare industry is a vast network of providers, insurers, pharmaceutical companies, and government programs. While many operate with integrity, the sheer amount of money involved makes the system vulnerable to fraud and abuse. When providers or organizations intentionally deceive the government, taxpayers, or patients for profit, the impact is serious, undermining trust, draining public funds, and risking patient care.

At Joe Cunningham Law, we are your trusted Charleston healthcare fraud attorney and we stand with those seeking to expose healthcare fraud. Joe Cunningham, the only former Congressmen in South Carolina currently practicing law, brings a unique perspective and deep commitment to representing whistleblowers. If you have evidence of healthcare fraud, a Charleston healthcare fraud attorney can help you make a difference. Joe Cunningham Law can help you navigate the process, protect your rights, and pursue a qui tam claim under the False Claims Act.

Understanding Qui Tam Claims and the False Claims Act

The primary legal tool for whistleblowers exposing fraud against the government is the False Claims Act (FCA), a powerful federal law that dates back to the Civil War. The FCA allows private citizens, known as relators or whistleblowers, to file a lawsuit on behalf of the government to recover funds lost due to fraud. These lawsuits are known as qui tam actions, a Latin phrase meaning “he who sues for the king as well as for himself.”

The FCA incentivizes whistleblowers by offering them a share of the recovered funds if their lawsuit is successful. This financial reward, typically ranging from 15% to 30% of the government’s recovery, acknowledges the significant risks and efforts whistleblowers undertake. The government often relies on these courageous individuals to expose fraudulent schemes that would otherwise go undetected.

When a whistleblower files a qui tam lawsuit, it is initially filed under seal, meaning it remains confidential and is not publicly disclosed. This allows the government to investigate the allegations without tipping off the defendants. The government then decides whether to intervene and take over the prosecution. Whether the government intervenes or not, the whistleblower, with their attorney, can often continue to pursue the claim.

The Alarming Reality of Healthcare Fraud in South Carolina

Healthcare fraud is not a victimless crime. It costs taxpayers billions each year, siphoning essential resources from programs like Medicare, Medicaid, and TRICARE, and potentially risking patient lives. The U.S. government has made combating healthcare fraud a top priority, recognizing its significant impact on the nation’s economy and the integrity of its healthcare system.

Identifying and stopping this illicit activity often depends on the courage of insiders, including employees, former employees, and competitors, who possess direct knowledge of the wrongdoing. Joe Cunningham Law helps whistleblowers file qui tam lawsuits under the False Claims Act to expose fraud and allow them to recover a portion of any financial recovery.

Common Examples of Healthcare Fraud

Healthcare fraud can be difficult to spot, especially when committed by large institutions or sophisticated billing departments. However, these are some of the most common forms of fraud we have seen in the Charleston area and beyond:

• Billing for services not rendered: This is one of the most straightforward forms of fraud. Providers bill Medicare, Medicaid, or other programs for treatments, procedures, or supplies that were never actually provided to patients. This can range from entirely fabricated claims to padding legitimate claims with services that did not occur.
• Upcoding: This involves billing for a more expensive or complex service than was actually performed. For example, a doctor might perform a routine office visit but bill it as an extended or highly complex examination to receive a higher reimbursement. Similarly, a medical equipment supplier might bill for a high-end motorized wheelchair while only providing a less expensive manual one.
• Unbundling: This occurs when a provider bills separately for services that should legitimately be billed together as a single, less expensive procedure to inflate reimbursement.
• Kickbacks and illegal referrals: This occurs when healthcare providers or organizations offer, solicit, or receive payments or other incentives in exchange for patient referrals or for prescribing certain drugs or using specific medical devices. The Anti-Kickback Statute makes it illegal to offer, pay, solicit, or receive remuneration in exchange for federal healthcare program business referrals.
• Billing for medically unnecessary services: This involves providing and billing for tests, procedures, or treatments that are not medically necessary for the patient’s condition. It often involves false diagnoses to justify the unnecessary services.
• Misrepresenting patient diagnoses or medical histories: Fraudulent providers may enter false diagnoses or more severe conditions into patient records to justify billing for more expensive treatments or to receive higher reimbursement rates. This defrauds the government and can have long-term implications for a patient’s medical history.
• Pharmaceutical fraud: This can encompass various activities, including drug manufacturers promoting drugs for uses not approved by the FDA, providing kickbacks to doctors to prescribe their drugs, or manipulating drug pricing. Pharmacies may also engage in fraud by billing for prescription drugs that were never dispensed or by substituting cheaper generic drugs while billing for more expensive brand-name ones.
• Durable medical equipment (DME) fraud: This involves providers billing for DME, like wheelchairs, oxygen tanks, or braces, that are not medically necessary, were never delivered, or are of a lower quality than what was billed.
• Falsifying cost reports: Certain healthcare entities, particularly nursing homes, receive reimbursement from submitted cost reports. Fraud can occur when these entities include personal expenses, inflated overhead costs, or other illegitimate expenditures in their reports to increase their reimbursement unlawfully.
• Identity theft and impersonation: While less common for large-scale fraud, some individuals or entities may use stolen patient or provider identities to bill for services or goods, or to obtain prescription medications for illicit purposes.
• Managed care organization (MCO) fraud: In a managed care environment, where providers receive a fixed payment per patient, fraud can involve denying medically necessary care to patients to increase profits or cherry-picking healthy patients to minimize costs.
• Home health and hospice fraud: This area has seen a rise in fraudulent schemes, including billing for services that are not provided, providing unnecessary home health or hospice care, or manipulating patient eligibility criteria to receive payments.

These practices are not just unethical. They are illegal, and they hurt taxpayers, patients, and the healthcare system. If you have witnessed fraud like this, consulting with our experienced Charleston healthcare fraud lawyers is crucial because you have legal protections and rights as a whistleblower.

Who Can Be a Healthcare Whistleblower?

You need not be a government official or executive insider to blow the whistle. In fact, many whistleblower cases begin with everyday healthcare employees, like nurses, billing specialists, lab technicians, coders, administrators, and contractors, who notice that something is wrong.

If you have seen fraud and are considering coming forward, our healthcare fraud attorneys in Charleston, SC, are here to support you. We will help you understand your rights under state and federal whistleblower laws, file a qui tam lawsuit if appropriate, protect your career, defend against retaliation, and maximize your potential whistleblower reward.

Joe Cunningham Law Shields Those Who Speak Out

Coming forward with evidence of fraud can be daunting. Whistleblowers often fear retaliation from their employers, including demotion, harassment, or wrongful termination. Federal and state laws recognize these risks and provide significant protections for individuals who report fraud against the government.

The False Claims Act includes robust anti-retaliation provisions. Under the FCA, employers are prohibited from discharging, demoting, suspending, threatening, harassing, or discriminating against an employee because they have taken lawful actions in furtherance of a qui tam action, or for trying to stop a violation of the FCA. If an employer retaliates against a whistleblower in violation of the FCA, the whistleblower can sue for damages, which may include:

• Reinstatement to their former position: If an employer terminates a whistleblower, they may be reinstated to their job.
• Back pay: This is compensation for lost wages and benefits from the date of the retaliatory action.
• Front pay: This is compensation for future lost earnings if reinstatement is not feasible.
• Special damages: These include damages for emotional distress, reputational harm, and other non-economic losses.
• Attorney fees and costs: The court may order the employer to pay the whistleblower’s legal fees and expenses.

Beyond the FCA, other federal and state laws may offer additional whistleblower protections, depending on the specific nature of the fraud and the whistleblower’s employment status. These laws may include Title VII, the Americans with Disabilities Act (ADA), and the Family and Medical Leave Act (FMLA). 

The Intersection of Whistleblower and Employment Law

Many whistleblower cases involve overlapping issues in employment law. Joe Cunningham’s experience in the public and private sectors provides a comprehensive understanding of these interconnected legal areas. Retaliation is not always as blatant as a direct firing. It can manifest in many forms, including:

• Demotion or reassignment to a less desirable position: This might involve a significant reduction in responsibilities, a transfer to a less prestigious department, or a change in reporting structure designed to marginalize the employee.
• Reduced pay or hours: An employer might cut a whistleblower’s salary, reduce their work hours, or eliminate opportunities for overtime.
• Negative performance reviews or disciplinary actions: An employer might suddenly criticize a whistleblower’s performance or initiate disciplinary procedures that were not previously warranted, creating a paper trail to justify future adverse actions.
• Exclusion from meetings or projects: Whistleblowers may be ostracized from important team discussions, denied access to key information, or excluded from projects essential to their professional development.
• Harassment or hostile work environment: This can involve verbal abuse, intimidation, social isolation, or other behaviors that make the work environment intolerable.
• Constructive discharge: Sometimes, the employer’s retaliatory actions may make working conditions so intolerable that the employee is forced to resign. This can be legally considered a constructive discharge and treated as a wrongful termination.

If you suspect your employer is retaliating against you for blowing the whistle on healthcare fraud, it is crucial to document everything. Keep detailed records of dates, times, specific incidents, and any witnesses. This evidence will be vital in building a strong case. Our healthcare fraud attorneys can help you assess your full legal options, potentially pursuing a qui tam claim, bringing an employment lawsuit, or both.

Why Choose Joe Cunningham Law as Your Charleston Healthcare Fraud Lawyer?

Joe Cunningham is not your average attorney. He is a former U.S. Congressman who understands how government programs work and how corruption and waste hurt everyday people. During his time in Congress, he fought to improve healthcare access, reduce fraud, and hold powerful interests accountable. Today, Joe uses that experience to protect South Carolinians who speak out against fraud. Here is why whistleblowers trust Joe:

• Congressional insight: Joe’s firsthand knowledge of government systems and agencies gives his clients a strategic advantage in whistleblower litigation.
• Personal commitment: Joe frequently contacts his clients, providing straightforward advice and honest expectations throughout the legal process.
• Proven advocate: Joe does not back down from a fight. If employers or corporations try to punish you for doing the right thing, he is ready to take them to court.
• Local focus, national reach: Based in Charleston and serving all of South Carolina, Joe works closely with federal partners and has the network to take on cases with nationwide implications.

Joe’s commitment to his constituents during his time in Congress included putting people first. This commitment is now fully channeled into advocating for whistleblowers.

Timing and Deadlines in a Whistleblower Case

There are strict deadlines for bringing a whistleblower case under the False Claims Act. You must typically file claims within six years of the fraud or three years from when the government learned of the fraud, but no later than ten years total. If you wait too long, you may lose your right to recover. Contact our healthcare fraud attorneys immediately if you have uncovered fraud.

Contact Our Charleston Healthcare Fraud Attorney Law Firm Today

If you have information about healthcare fraud, the time to act is now. Delays can impact your claim’s viability and potentially diminish the government’s recovery and your potential reward. The sooner you speak with our team at Joe Cunningham Law, the better equipped you will be to navigate the complex legal landscape.

Contact us today for a free consultation. Your initial consultation will be confidential, allowing you to openly discuss your concerns and the evidence you possess without fear. We will listen to your story, explain your rights, and help you understand the path forward. By coming forward, you can help recover stolen taxpayer dollars and contribute to a more ethical and accountable healthcare system for everyone in South Carolina and beyond.