CMS pays a False Claims Act whistleblower between 15% and 30% of any monies collected on the claims they submit. It’s no wonder that the Justice Department reports that 98% of all healthcare False Claims Act (FCA) cases are whistleblower-initiated.
What this means is that every one of your employees is a potential whistleblower. In 2020, whistleblowers were awarded more than $309 million – an amount that the government seems intent on growing.
Medicare and Medicaid fraud false claims act whistleblower.
CMS fraud allegations are managed through FCA regulations. If someone makes a fraudulent Medicare claim, FCA violations come into play. The FCA rules allow for whistleblower complaints related to Medicare and Medicaid Fraud.
In addition to federal fraud allegations, whistleblower complaints could also result in state charges based on federal matching money. Most states have now implemented versions of the FCA with similar regulations and consequences.
The HHS-OIG gives incentives to states to create their own false claims act statutes. States can receive “a 10-percentage-point increase in their share of any amounts” recovered under the relevant laws.[46] The state’s FCA statute must mirror the federal regulations in three ways to gain approval. State statutes must:
- Be at least as effective in rewarding qui tam actions
- Contain civil penalties in alignment with federal penalties
- Increase civil penalties at the same rate as the federal ones
FCA Practice Violation Claims false claims act whistleblower.
If your practice is found guilty of violating the FCA, you could have to pay three times the dollar amount associated with the violation. Each false claim penalty is from $5,000 to $10,000. Penalties can be applied based on the number of related claims filed over a period of time. Below you’ll find a list of common FCA violations levied against practices:
- Billing for services not performed
- Billing for ineligible persons
- Knowingly submitting, or conspiring with others to file false Medicare/Medicaid claim for payment
- Knowingly utilizing or conspiring to use a false record to file a Medicare/Medicaid claim for payment
- Submitting false information to Medicare/Medicaid to reduce or avoid having to pay money
- Conducting medical treatments that are not necessary
- Referring patients improperly
- Failure to comply with Medicaid “best practices”
- Failure to accurately enroll qualified Medicaid patients into sponsored programs
Whistleblower Claims Poised to Increase
In 2020, new FCA enforcement cases increased by 14%. This increase suggests that government efforts to stop fraud using the FCA are growing. Enforcement has continued to intensify in 2021, and whistleblowers are expected to play a significant role this year and beyond.
There are things you can do to mitigate whistleblower complaints. In many cases, whistleblowers try to inform their employers before ever going to the government, but their complaint is ignored. Accordingly, adding an employee complaint response process at your practice can go a long way toward safeguarding against potential FCA whistleblower allegations. Kelly Holden, JD, will walk you through how you can set up a successful employee complaint response process to protect your practice from whistleblower allegations. Her online training, Stop Whistleblower False Claims Act Complaints and Resulting Penalties tells you everything you need to know. Register for this training now!
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