On July 23, 2021, a notice of dismissal was filed indicating that an Alabama health system agreed to pay $1 million dollars to resolve a federal qui tam lawsuit alleging that it violated the False Claims Act. The Government’s multi-year investigation, which began from a whistleblower complaint, examined whether the Alabama health system knowingly violated the False Claims Act by improperly billing Alabama Medicaid for Basic Living Skills services and failing to return overpayments to the Alabama Medicaid Agency, which constitutes a “reverse false claim” actionable under 3729(a)(1)(G) of the False Claims Act.
The settlement resolves allegations that, from October 1, 2012 through December 31, 2019, the Alabama health system (1) knowingly submitted to Medicaid claims for reimbursement for services that were billed without complete and correct documentation, billed in duplicate, over-billed, or otherwise improperly billed, and/or (2) knowingly made, used, or caused to be made or used, false records or statements material to the Alabama health system obligation to return overpayments to Medicaid based on such improper billing procedures, and/or (3) knowingly, intentionally, or recklessly failed to repay, or to exercise reasonable diligence to determine whether it was obligated to repay, Medicaid for the Alabama health system improper claim submissions and their attendant overpayments.
The lawsuit was initially filed in the United States District Court for the Middle District of Alabama by a former employee of the Alabama health system, under the qui tam or whistleblower provisions of the False Claims Act. Pursuant to these provisions, a private citizen can bring suit on behalf of the United States and share in any recovery. The United States will receive $743,193.00 of the $1 million dollar settlement, 19% of which will go to the relator as her share of the Government’s recovery in the matter. The remaining $256,807.00 will be paid to the Alabama Medicaid Agency.
Compliance Perspective
Issue
All members of the healthcare team should be aware of what may be considered a false claim. The healthcare team should also be knowledgeable about qui tam and feel assured that reporting is a protected action. Fear of retaliatory firing is a very real concern for employees. Investigations should be conducted fairly to verify any claims of wrongdoing. The facility’s Compliance and Ethics Program focus is on protecting government funds from fraud, waste, and abuse and detecting criminal, civil, and administrative violations while promoting quality of care. The Compliance and Ethics Committee, when operated appropriately, will assist in detecting false claims. The Compliance and Ethics Committee should also be monitoring events that could lead to retaliation. More information is available in the Med-Net Corporate Compliance and Ethics Manual, Chapter 1, Compliance and Ethics Program.
Discussion Points
- Review your policies and procedures for operating an effective Compliance and Ethics Program. In addition, review your policy and procedure for preventing and reporting a false claim and for ensuring whistleblower protection. Update your policies and procedures as needed.
- Train all staff on your compliance and ethics policies and procedures upon hire and at least annually. Also, train all staff on the False Claims Act, whistleblower protection, 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 these trainings occurred and file the signed document in each employee’s education file.
- Periodically audit staff understanding to ensure that they are aware of what should be done if they suspect a false claim or illegal kickback 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. Also periodically perform audits to ensure all are aware of compliance and ethics concerns and how to report any concerns of compliance and ethics violations.
FOR MORE INFORMATION ON THIS TOPIC VIEW: FRAUD MODULE 3 – MASTERING LEGAL IMPLICATIONS AND ANTITRUST LAWS.
