Federal False Claims Act

Common Types of Fraud

We comply with the Federal Civil False Claims Act (FCA), which is intended to prevent and detect fraud, waste and abuse of government funds. Some of the most common types of fraud, which have been exposed and prosecuted include:

• Health Care Fraud
• Hospital and Emergency Room Fraud
• Pharmaceutical Fraud
• Medicare Fraud
• Defense Contractor Fraud
• Energy Fraud
• Construction and Procurement Fraud
• Research Fraud
• Financial Industry Fraud

Fraudulent Practices

The Federal False Claims Act prohibits anyone or any entity from knowingly:

• submitting false/fraudulent documentation to the government for payment or approval;
• making, using, or previously made false/fraudulent documentation pertinent to the claim;
• conspiring to defraud the government by getting a false/fraudulent claim approved or paid;
• returning only a portion of government money or property with the intent to defraud the government;
• making or delivering a document, which certifies receipt of property without completely knowing if the information on the receipt is true;
• buying public property or accepting it as a pledge or obligation/debt from an officer or employee of the government or a member of the armed forces, who is not authorized to sell or pledge this property; and,
• using false documentation to avoid or decrease an obligation to pay or transmit money or property to the government.

Fraudulent Practices in Health & Medical Care

Most False Claims Act violations occur in the healthcare and medical industries. Examples include:

• billing for services that were not delivered;
• billing twice for the same service;
• billing for more expensive service than was provided;
• seeking reimbursement for services that:
  • are not medically necessary for a client’s condition; and/or,
  • fail to meet professionally recognized standards for health care;
• making false statements regarding claims for payment;
• failing to provide services that are required in the scope of the daily rate;
• concealing an event affecting initial or continued payments by Medicaid/Medicare;
• misrepresenting Agency credentials;
• offering financial rewards, which are often unlawful, to individuals who:
  • utilize or promote Agency services;
  • send clients to utilize Agency services;

Reporting Financial Fraud Against Federal Government

If you believe you know of, or suspect financial fraud against the Federal Government, including fraud against other federally funded entities, you can:

• Report your suspicions to our Agency, if you are hesitant to contact officials.
• Report your suspicions directly to officials by:
  • reporting the fraud to the federal agency that has been defrauded,
  • notifying the Federal Bureau of Investigation (FBI; or,
  • filing a lawsuit on behalf of the government against the party alleged to have violated the False Claims Act (called “qui tam” action).
• Proof of a specific intent to defraud is not required to report suspected fraud.

Medicaid Fraud

Medicaid fraud is an intentional deception or misrepresentation made by a health care provider or a Medicaid recipient with the knowledge that the deception could result in some unauthorized benefit to him or herself or some other person. It includes any act that constitutes fraud under federal or state law related to Medicaid, e.g.:

• soliciting, paying or receiving kickbacks, remuneration, or anything of value in exchange for referrals of individuals who will receive treatment paid for by government healthcare programs (e.g., Medicare and Medicaid).
• accepting referrals of Medicare patients when the referring Physician has a financial relationship with the Agency;
• submitting false statements or certifications of compliance to receive payment by the government health program;
• falsifying cost reports and other documents to meet eligibility requirements for Medicare/Medicaid fund;
• billing for services not provided;
• billing for medically unnecessary services;
• billing for a health service that is more expensive than the service provided;
• charging for items or services separately instead of one package;
• double billing.

Reporting Medicaid Fraud

Suspicions or observations of Medicaid Fraud can be reported to:

1. Office of the Inspector General Phone: 1-800-HHS-TIPS (1-800-447-8477) or TTY 1-800-377-4950 Fax: 1-800-223-8164 Email: HHSTips@oig.hhs.gov
2. Department of Public Welfare Phone: 866-DPWTIPS

Penalties for Violating False Claims Act

Anyone who knowingly or intentionally submits a false claim to the federal government is liable for:

• Civil Penalty
  • three times the amount of damage the government paid for the false claim; plus,
  • up to $11,000 per false claim.
• Criminal Penalty
  • $50,000; and/or,
  • imprisonment.
  • The term “knowingly,” means:
    • having actual knowledge of the information;
    • acting in deliberate ignorance of the truth or falseness of the information; or,
    • acting in reckless disregard of the truth or falseness of the information.

Whistleblower

A Whistleblower is a person who exposes fraudulent activity or information that has been deemed illegal, unethical, or not correct under the False Claims Act.

Whistleblower Protection

The False Claims Act offers Whistleblower protection, to any individual or non-governmental organization that has evidence of fraud against government contracts and programs to:

• make reports to the government; or,
• sue on behalf of the government to recover the stolen funds.

The Statute prohibits retaliation measures (e.g., threats, harassment, discrimination, suspension, demotion or termination of employment) for reporting fraud and abuse.

Whistleblower Compensation

A Whistleblower may be entitled to compensation. The amount depends on whether the  government recovers the funds, or the Whistleblower’s own lawsuit recovers the funds. They range from 15 to 30 percent of the total amount recovered by the government.

Whistleblower Lawsuit

To begin a whistle blower lawsuit (called a qui tam lawsuit), the Whistleblower must file a sealed complaint in the appropriate court and serve the complaint on the U.S. Attorney for that district. The government then has 60-days to determine whether it will prosecute the case. If the government declines to prosecute the case, the Whistleblower may prosecute it privately.