More than $5.6 billion in settlements and judgments have been recovered by the Department of Justice Department (DOJ) related to civil cases involving fraud and false claims in fiscal year 2021. This is the second largest annual total in False Claims Act history, and the largest since 2014. Total recovery now totals more than $70 billion.
In 1986, Senator Charles Grassley and Representative Howard Berman led the successful efforts in Congress to amend the False Claims Act to, among other things, encourage whistleblowers to come forward with allegations of fraud. In 2009 and 2010, further improvements were made to the False Claims Act and its whistleblower provisions. Congress strengthened the False Claims Act by increasing incentives for whistleblowers to file lawsuits alleging false claims on behalf of the government. These whistleblower, 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%. Whistleblowers filed 598 qui tam suits in fiscal year 2021, which resulted in $1.6 billion recovered under the qui tam provisions of the False Claims Act. The government paid $237 million in fiscal year 2021 to whistleblowers who exposed fraud and false claims. The number of lawsuits filed under the qui tam provisions of the False Claims Act in fiscal year 2021 averaged over 11 new cases every week.
In fiscal year 2021 healthcare fraud was the leading source of False Claims Act settlements and judgements. Other leading sources include:
- Combatting the Opioid Epidemic
- Medicare Advantage Program (Medicare Part C)
- Unlawful Kickbacks
- Unnecessary Medical Services
- Procurement Fraud
- COVID-Related Fraud
- Other Fraud Recoveries
Compliance Perspective
Issue
All members of the healthcare team must be aware of what may cause submission of a false claim, including the ordering of unnecessary drugs, treatments, or equipment. Failure to promptly report a false claim can result in lawsuits, fines, and other sanctions. An effective compliance and ethics program can help raise staff awareness and ultimately reduce fraud, waste, and abuse of government funds by empowering the healthcare team to participate actively in preventing and detecting criminal, civil, and administrative violations and promoting quality of care. Routine audits should be conducted, and the results of the audits should be reported at the compliance and ethics committee meetings and in reports to the governing body.
Discussion Points
- Review your policies and procedures for operating an effective compliance and ethics program to ensure that identifying and reporting of false claims or kickbacks is part of your policy. Ensure that your policies are reviewed at least annually and updated when new information becomes available.
- Provide education to nursing and business office personnel on their responsibility to identify and report any concerns that unnecessary medications, treatments, supplies, or equipment are being ordered for residents, and to ensure that double billing does not occur for services provided by vendors or contracted staff for residents/patients covered by Medicare. Awareness training is an important part of your facility’s efforts to prevent false claims from being submitted. Train all staff on your compliance and ethics policies and procedures upon hire and at least annually, including what can be considered a false claim or a kickback. 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 their responsibility to identify and report compliance and ethics concerns and understand that it is their responsibility to report violations to their supervisor, the compliance officer, or via the anonymous hotline in a timely manner.
