The Department of Justice (DOJ) recovered more than $2.2 billion in settlements and judgements from civil cases involving fraud and false claims against the government in fiscal year ending September 30, 2020. More than $1.8 billion of the $2.2 billion in settlements and judgements involved the healthcare industry, including drug and medical device manufacturers, managed care providers, hospitals, pharmacies, hospice organizations, laboratories, and physicians. The amounts included in the $1.8 billion reflect only federal losses, and in many cases, DOJ was instrumental in recovering additional tens of millions of dollars for state Medicaid programs.
The DOJ has recovered more than $64 billion since 1986, when Congress strengthened the civil False Claims Act. In 1986, Congress strengthened the act by increasing incentives for whistleblowers to file lawsuits alleging false claims on behalf of the government. These whistleblowers, or qui tam actions, comprise a significant percentage of the False Claims Act cases that are filed. If the government prevails in a qui tam action, the whistleblower, also known as the relator, typically receives a portion of the recovery ranging between 15 and 30 percent. Whistleblowers filed 672 qui tam suits in fiscal year 2020, and in this past year the department recovered over $1.6 billion in these and earlier-filed suits.
The DOJ’s healthcare fraud enforcement efforts restore funds to federal programs, including Medicare, Medicaid, and TRICARE. The DOJ’s pursuit of healthcare fraud prevents billions more in losses by deterring others who might otherwise try to cheat the system for their own gain.
Compliance Perspective
Issue
It is extremely important that all members of the healthcare team are aware of what may be considered a false claim. Ensure that all staff are aware that a false claims violation can occur whether it was intentional or not intentional. Failure to promptly report a false claim can result in lawsuits, fines, and other sanctions.
Discussion Points
- Review policies and procedures for preventing and reporting a false claim. Update your policies and procedures as needed.
- Train all staff on the False Claims Act and what can be considered a false claim. Include information on how to report concerns and suspected violations, and that prompt reporting is mandatory. Document that the trainings occurred and place in each employee’s education file.
- Periodically audit staff to ensure that they are aware of what should be done if they suspect a false claim has occurred, whether intentionally or unintentionally. Conduct audits of documentation and billing routinely to prevent and detect errors before they progress to a false claim.
FOR MORE INFORMATION ON THIS TOPIC view: UNDERSTANDING AND USING THE MEDICARE TRIPLE CHECK PROCESS.
