False Claims Act and Health Care Fraud

Health care fraud is a serious problem in the U.S., with costs reaching an estimated $100 billion annually. Health care fraud has become so significant that the U.S. Department of Justice has established a Health Care Fraud Unit to address the problem.

The False Claims Act (FCA) is a federal law that the U.S. government uses to deal with health care fraud cases and allows private citizens to get involved. This article will discuss the federal False Claims Act, health care fraud, and where to go for help.

What Is the False Claims Act?

The FCA is the big stick that the federal government uses against those who file fraudulent claims against it, especially those related to health care. False Claims Act violations can result in penalties upwards of $10,000 for each false claim. This is on top of three times the actual damages suffered by the federal government. As a result, the act can be quite effective.

An important aspect of the FCA is that it allows private people to sue perpetrators of fraud on behalf of the federal government. This is its qui tam provision. People who become aware of fraudulent health care claims can sue under the FCA through a qui tam action. They may receive up to 30% of any funds recovered if successful. It's not a bad incentive.

Examples of Health Care Fraud

Health care fraud encompasses a spectrum of deceptive practices. It often includes fraud aimed at exploiting government-funded programs like Medicaid. Kickbacks, where providers get improper payments in exchange for referrals, represent a common form of fraud within the Medicaid program, violating the anti-kickback statute.

Another common form of fraud is upcoding. Upcoding involves billing for more expensive services than provided, while false records and deliberate ignorance of the falsity of information supplied for reimbursement further erode the system's integrity. Such actions show a specific intent to defraud, often coupled with actual knowledge or reckless disregard for the truth, all at the expense of government funds for legitimate patient care.

Other examples of fraud in the health care industry include:

• Misrepresenting dates/locations/providers of service
• Waiving deductibles or co-payments
• Falsifying a diagnosis to justify treatments
• Billing each step of a procedure as a separate procedure (this is called "unbundling")
• Tampering with medical records
• Forging signatures

How Can You Prevent Health Care Fraud?

As you can see, the health care industry deals with many costly false claims. If you're interested in helping to prevent health care fraud, here are a few tips:

• Protect your insurance cards and benefit information
• Don't accept unnecessary equipment, products, or treatments
• Be suspicious of medical offices that lack normal medical equipment and fail to perform normal medical procedures during visits (taking blood pressure, etc.)
• Review your medical billing statements carefully to ensure that they accurately reflect the treatments/equipment you received

If you do suspect health care fraud, there are a variety of reporting methods available. But, if the fraud involves claims to the federal government, consider using the qui tam provisions of the FCA, as you could get awarded a percentage of the funds recovered.

Reporting Fraud Under the FCA

Whistleblower protections under the FCA serve as a shield for people uncovering fraudulent activity within government contracts and programs. Those brave enough to expose such deceit are safeguarded against retaliation and are entitled to remedies such as reinstatement, back pay, and reasonable attorney's fees should they face adverse actions. Also, the FCA empowers whistleblowers to start civil actions against those making false statements to the government, ensuring accountability and preserving the integrity of public funds.

Learn More About Health Care Fraud

Health care fraud isn't a victimless crime. It's one reason everyone's health care costs are so high. If you're in a position to uncover health care fraud, you could get rewarded for taking action to stop it. Before you do, speak with an attorney to understand your rights and options. Contact a whistleblower-qui tam attorney near you today to learn more.