Laboratory Fraud Whistleblowers: Connecting What You Saw to the Claim

A laboratory fraud whistleblower can connect what was ordered, performed or billed to an unnecessary test, a false claim or a payment for referrals. You may know why every patient gets the same panel, why a test code changes before the bill goes out, or what a physician’s office was promised for sending specimens. The laboratory’s claim tells the payer what it wants paid. Someone inside the transaction can explain how that claim came to exist. When Medicare pays for unnecessary tests, taxpayers fund laboratory revenue that serves no patient need.

That person may work at the laboratory, the referring practice or the company selling the tests. A lab whistleblower may also be a competitor or an outside marketer. Each sees a different part of the business and holds different evidence. We connect that account to the order, the testing and the money.

What a Laboratory Fraud Whistleblower Can Know

An employee, physician, marketer or competitor can bring firsthand knowledge of how laboratory business was obtained and billed. Your position determines which part you can explain: the clinical decision, the work performed, the claim submitted or the payment that brought the specimen in.

Technical and Quality Staff Know the Testing Process

A laboratory director or technician can compare the test requested with the work actually performed and the result released. Quality staff may know whether the testing process supported that result, who raised a problem and what management did next.

At Alere, a senior quality-control analyst brought the whistleblower case behind a settlement over allegedly unreliable diagnostic devices. The useful knowledge came from the quality side of the business. A person who understands the testing can explain a problem that a paid claim alone would never show.

Billing Staff Know What the Payer Was Told

Billing staff see the service code, diagnosis information, payer and charge. Their contribution can be the difference between the test ordered and the test billed, a charge for work never performed, or unbundling that turns a panel into separately billed components.

In a whistleblower complaint involving Labcorp, a former employee alleged that the company double or triple billed Walter Reed by charging for each sample analyzed when its outside testing provider charged for the child’s or fetus’s report. The allegation turned on what the laboratory bought and what it charged the government for the same work.

Physicians and Office Managers Know Why the Test Was Ordered

The referring office knows what the clinician requested and what the patient record says about the need for it. An office manager or medical assistant may also know who completed the requisition, whether a panel arrived preselected and whose instruction controlled the referral.

The clinical detail can be the heart of a case. A pathologist brought the Piedmont Pathology whistleblower matter over the sequence of routine and special stains. The theory was that a pathologist should first review the routine stain before deciding whether a special stain was needed. Knowing when the decision should happen made the alleged shortcut visible.

Salespeople and Marketers Know What Won the Account

Sales staff can explain what the laboratory offered a practice and how compensation followed the business it generated. The commission schedule, marketing invoice and referral arrangement can tell the same story from different sides.

The whistleblowers in the Admera Health commission case were co-founders of a former third-party marketer for the laboratory. The people on the receiving side of the commissions brought the case about those payments.

Collection Staff Know What the Practice Received

Phlebotomists and other collection staff see the specimen and the referral relationship at the same time. They may know which office duties they performed, who paid them and whether their work extended beyond collecting specimens for the laboratory.

That distinction matters when free labor becomes part of the sales offer. The government’s laboratory fraud alerts have addressed staff placed in physicians’ offices, equipment and other benefits. A contract’s description of specimen collection can be compared with the work the person actually did for the practice.

The offer can also reach the patient’s bill. In the Health Diagnostic Laboratory and Singulex cases, the government alleged that the laboratories paid physicians processing and handling fees for referrals and routinely waived patient co-pays and deductibles. Office and collection staff may know both what the practice received for sending a specimen and what patients were told they would owe.

Competitors Know the Offer From the Other Side

A competitor may know the referral terms it is being asked to match, the testing being sold or the way a rival handles an order. That knowledge can connect a commercial practice to a specific service or claim.

Omni Healthcare was a corporate whistleblower in the Millennium Health cases. It also brought a separate complaint involving OPKO Health and BioReference, alleging that orders for a routine blood count became more expensive tests with a differential. The comparison was concrete: what the physician requested against what the laboratory ran and billed.

What Evidence Is Needed to Prove Fraud?

Laboratory fraud evidence connects the order and the patient’s clinical circumstances to the test performed, the result, the claim and the payer. When referrals were bought, the payment or benefit belongs in that same account. Your contribution may be the original order, the billing instruction or the conversation explaining why a test was added. Our laboratory fraud evidence page examines those connections in detail.

What Qualifies as a Whistleblower Complaint?

A laboratory whistleblower complaint connects specific knowledge of the testing or referral arrangement to alleged false claims involving government money. We assess what you know about the practice, the payer and the decisions behind it.

That account can come from the clinician whose order changed, the biller who saw the change or the marketer who understood the referral payment. A person’s job title explains where the knowledge came from. The transaction explains how it matters to the case.

What Is a Whistleblower Case Under the False Claims Act?

A whistleblower case under the False Claims Act is a civil case brought on the government’s behalf over alleged fraud involving government money. In healthcare, that can include billing for unnecessary laboratory tests or buying referrals. It is also called a qui tam case. Laboratory cases involving Medicare, Medicaid and TRICARE connect the testing or referral arrangement to claims paid by those programs.

Referral payments can be part of that connection. In the Millennium Health case, the government alleged that free urine test cups came with a condition: physicians had to send the specimens back for additional laboratory testing. The Department of Justice alleged violations of the Anti-Kickback Statute and Stark Law. The free item helped secure the next bill.

What Is the Reward for Medicare Fraud Whistleblower?

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

Millennium agreed to pay $227 million to resolve the urine drug testing allegations. The Justice Department announced $30.35 million for the whistleblowers from that recovery.

In the Logan Laboratories and Tampa Pain settlement, the laboratory, clinic and two former executives agreed to pay a total of $41 million. The Department of Justice said the whistleblowers would receive approximately $7.79 million. The testing policy connected work at the clinic to claims from the laboratory, and the resolution covered both.

In the SmithKline Beecham Clinical Laboratories case, the district court’s final award to one whistleblower was about $26 million.

How to Report Laboratory Fraud?

Start with our whistleblower experts and the testing, billing or referral practice you know. We assess how your account connects to a potential False Claims Act case and find whistleblower lawyers with the laboratory experience it needs.

If your questions concern confidentiality, retaliation or your own involvement in the arrangement, we address those with you and the whistleblower lawyers. Your first conversation can begin with what you saw and why it concerned you.

Your View Inside the Laboratory Business

If you know who chose the panel, changed the claim or paid for the referrals, speak to one of our whistleblower experts about the laboratory practice you saw. We build the case around that knowledge, bring in laboratory fraud whistleblower lawyers who understand the testing and payment arrangements, and stand beside you through the pursuit of a recovery.