The head of the Justice Department’s Civil Division announced on February 7, 2023, that settlements and judgments under the False Claims Act exceeded $2.2 billion in the fiscal year ending Sept. 30, 2022, which is the second highest number of settlements in history. According to the announcement, the government and whistleblowers were party to 351 settlements and judgments. Recoveries since 1986, when Congress substantially strengthened the civil False Claims Act, now total more than $72 billion.
Of the more than $2.2 billion in False Claims Act settlements and judgments reported by the Department of Justice (DOJ) this past fiscal year, over $1.7 billion related to matters that involved the healthcare sector, including drug and medical device manufacturers, durable medical equipment, home health and managed care providers, hospitals, pharmacies, hospice organizations, and physicians. The amounts included in the $1.7 billion reflect recoveries arising only from federal losses, and, in many of these cases, the department recovered additional amounts for state Medicaid programs. The recoveries in fiscal year 2022 also reflected the department’s focus on new enforcement priorities, including fraud in pandemic relief programs and alleged violations of cybersecurity requirements in government contracts and grants.
Whistleblower, or qui tam, actions comprise a significant percentage of the False Claims Act cases that are filed. Qui tam cases may be pursued by the government or the whistleblower, and this past year significant recoveries were obtained by both. When a qui tam action is successful, the whistleblower, also known as the relator, typically receives a portion of the recovery ranging between 15 percent and 30 percent. Whistleblowers filed 652 qui tam suits in fiscal year 2022, and this past year the department reported settlements and judgments exceeding $1.9 billion in these and earlier-filed suits.
The full announcement from the DOJ can be read here. It provides a summary of notable cases in different categories such as Unnecessary Services and Substandard Care, Unlawful Kickbacks, Fraud and Abuse in the Medicaid Program, Drug Pricing, etc.
To view the Fraud Statistics Overview from October 1, 1986, through September 30, 2022, click here.
Compliance Perspective
Issue
In fiscal year 2022, healthcare fraud remained a leading source of False Claims Act settlements and judgments. The provision of unnecessary medical services not only wastes taxpayer funds but also can expose patients to harmful procedures and treatments or cause them to forego other potentially more effective treatments. The False Claims Act imposes treble damages and penalties on those who knowingly and falsely claim money from the United States or knowingly fail to pay money owed to the United States.
Discussion Points
- Review your policies and procedures for preventing and reporting a false claim and for conducting a Triple Check Process to verify accuracy of Medicare claims. Ensure that your policies are reviewed at least annually and updated when new information becomes available.
- Train all staff upon hire and at least annually on your compliance and ethics policies and procedures and on what can be considered a false claim. Provide training to appropriate staff on the Triple Check Process for ensuring accuracy of all Medicare Part A billing and supporting documentation before claims are submitted. Members of the compliance and ethics committee should periodically receive additional training on compliance and ethics issues in healthcare. Document that these trainings occurred and file the signed document in each employee’s education file.
- Periodically perform audits to ensure all staff are aware of compliance and ethics concerns and understand their responsibility to report any potential compliance and ethics violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline. Audit to ensure that the Triple Check Process is being followed each month before claims are submitted to Medicare, and that any identified irregularities are corrected.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
