Whistleblower-Initiated Enforcement Actions against Health Care Fraud and Abuse in the United States, 1996 to 2005

2 September 2008 | Volume 149 Issue 5 | Pages 342-349

Federal regulators have aggressively prosecuted health care fraud since the early 1990s, leading to billions of dollars in financial recoveries. Nearly all major cases today are qui tam actions, involving whistleblowers with inside knowledge of the allegedly illegal schemes. This article documents the outcomes of major enforcement actions and describe the schemes, defendants, and whistleblowers involved. The authors obtained an inventory of unsealed federal qui tam litigation targeting health care fraud that was resolved between 1996 and 2005 from the U.S. Department of Justice and gathered further information from publicly available sources. Among 379 cases, $9.3 billion was recovered, with more than $1.0 billion paid to whistleblowers. Case frequency peaked in 2001, but annual recoveries increased sharply from 2002 to 2005. Whistleblowers were frequently executives or physicians, and 75% were employees of defendant organizations. The 13 (4%) cases against pharmaceutical companies accounted for $3.6 billion (39%) of total recoveries. This study illuminates the scope and characteristics of qui tam fraud litigation and the whistleblowers who animate this important tool for addressing waste in the health care sector.

Author and Article Information

From Brigham and Women's Hospital, Boston, Massachusetts, and University of Melbourne, Melbourne, Victoria, Australia.

Disclaimer: This study was not submitted for institutional review board review because it is based on publicly available data and involved no health records (45 Code of Federal Regulations [CFR] 46.102).

Acknowledgment: The authors thank Sarah Weston, Ilina Chaudhuri, Rehana Gubin, and Jonathan Vance for their research assistance.

Grant Support: By an Agency for Healthcare Research and Quality Post-Doctoral Fellowship in Health Services Research at the Harvard School of Public Health (Dr. Kesselheim).

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Aaron S. Kesselheim, MD, JD, MPH, Division of Pharmacoepidemiology and Pharmacoeconomics, 1620 Tremont Street, Suite 3030, Boston, MA 02120; e-mail, akesselheim{at}partners.org.

Current Author Addresses: Dr. Kesselheim: Division of Pharmacoepidemiology and Pharmacoeconomics, 1620 Tremont Street, Suite 3030, Boston, MA 02120.

Dr. Studdert: University of Melbourne Law School, Suite 0737, Victoria 3010, Australia.