Contact our Georgia national whistleblower lawyers today. Call us at 770-643-1606

Health Co. Asks High Court To Rein In FCA Pleading Rules

Healthcare Company Whistleblower Lawyer

Full Article here.

Molina Health has urged the U.S. Supreme Court to rein in pleading requirements for False Claims Act whistleblowers, saying that a circuit divide has loosened standards that will become a broader cudgel for contractual and regulatory issues.

The managed care firm — accused by former contractor Thomas Prose of improperly billing the government for Medicaid services — says the high court must reverse a Seventh Circuit decision and instead conclude that Federal Rules of Civil Procedure Rule 9(b) requires whistleblower-plaintiffs like Prose to allege specific false claims that Molina may have made to the government.

The company also wants the court to rule that an omission alone doesn’t necessarily constitute a false or fraudulent claim under the FCA, according to the writ, filed Feb. 14. Molina warned that inaction or an adverse ruling would further transform the FCA — meant specifically to catch fraudulent billing — into a dragnet for “fishing expeditions,” according to the writ.

“The FCA is one of the most frequently litigated statutes in the U.S. Code,” the writ argues. “Unless this court grants certiorari and holds that a request for payment that makes no specific representations cannot be treated as if it contains an implied false certification, the FCA will become precisely what this court has warned against: ‘a vehicle for punishing garden-variety breaches of contract or regulatory violations.'”

According to Prose’s 2017 lawsuit, his company GenMed ended a contract to provide Molina with care coordination services at nursing homes, but Molina kept billing Medicaid as though GenMed was providing the services. The government paid Molina a set rate per patient regardless of specific services they received, and Molina says it didn’t make fraudulent claims because it never requested payment for specific required services it did not provide.

U.S. District Judge Virginia M. Kendall dismissed the lawsuit against Molina in June 2020, finding that the allegations weren’t specific enough, but the Seventh Circuit reversed that decision last year.

The appellate court concluded in a 2-1 decision in August that Prose has plausibly argued that Molina unit Molina Healthcare of Illinois knew that services it failed to provide were a material part of its Medicaid managed care benefits contract. It also concluded that submitting a claim to the federal government carries the “implied” certification that a claimant complied with the underlying conditions of their contract, meaning an omission is tantamount to a false claim.

Chief Circuit Judge Diane S. Sykes issued a strongly worded dissent, asserting that her colleagues’ position broke with the circuit’s own precedent on Rule 9(b) and conflicted with the high court’s landmark ruling in Universal Health Services Inc. v. United States ex rel. Escobar page2image38116464, which rejected “implied” certification as a theory of FCA liability and found that an alleged false claim must be material to the government’s decision to pay, according to the writ. Molina raised similar arguments in a petition for en banc review last month.

The Eleventh Circuit joined five other circuits — the Third, Fifth, Ninth, Tenth and D.C. — in relaxing false claim pleading requirements, according to the writ. The First, Second, Fourth, Sixth, Eighth and Eleventh circuits have all held that plaintiffs must state particular false claims.

The split has long vexxed whistleblowers and government contractors alike.

A number of courts have also addressed the omission question, with the Fourth, Seventh, and D.C. circuits holding that omissions can constitute false or fraudulent statements, and the Third, Fifth, Ninth, and 11th circuits finding otherwise.

The divide has come before the high court several times before, periodically drawing the justices’ attention, but never winning certification. Two other petitions pending before the Supreme Court raise identical questions about specificity of claims, but the justices should take up Molina’s petition, the Fortune 500 company says, because it raises the additional question about whether an omission constitutes a falsehood.

Alternatively, the court should hold its petition pending a decision in either of those cases — Johnson et al. v. Bethany Hospice and Palliative Care LLC from the 11th Circuit and United States ex rel. Owsley v. Fazzi Assocs. Inc. out of the Sixth Circuit — if it decides to review them instead, Molina said.

Last month, the Supreme Court invited U.S. Solicitor General Elizabeth B. Prelogar to weigh in on the Bethany case, which involves a Georgia hospice company’s alleged kickback scheme.

Prose attorney Bruce C. Howard told Law360 on Tuesday that the Seventh Circuit ruling should stand.

“We continue to believe that there’s little likelihood that the Supreme Court will grant the petition for cert,” he said. “As Molina noted, one of the issues is already subject to a pending petition. Secondly, the Seventh Circuit unanimously denied a petition for rehearing en banc. We believe they got it right.”

Prose is represented by Bruce C. Howard of Siprut PC, and Neil M. Rosenbaum, Damon E. Dunn and Paul M. King of Funkhouser Vegosen Liebman & Dunn Ltd.

Molina is represented by Kelly Perigoe, Albert Giang, Jeffrey S. Bucholtz, Ashley C. Parrish, Quyen L. Ta, Anne M. Voigts, and Matthew V.H. Noller of King & Spalding LLP.

The case is Molina Healthcare of Illinois Inc. et al., Petitioners v. Thomas Prose, case number 21- 1145, in the U.S. Supreme Court.

Full Article here.  |  The Bothwell Law group does not claim ownership of this article.


About the Bothwell Law Group:

Since 1996, the Bothwell Law Group has earned a national reputation for successful representation of whistleblowers in federal and state courts across the United States, and is one of only a handful of firms exclusively representing whistleblowers. Bothwell Law Group’s cases have resulted in the recovery of more than $400 million for the United States treasury and in the payment of millions of dollars in whistleblower rewards. Inquiries may be directed to Mike Bothwell at (770) 643‐1606, email

Universal Health Services, Inc. And Related Entities To Pay $122 Million To Settle False Claims Act

False claims act

Universal Health Services, Inc. And Related Entities To Pay $122 Million To Settle False Claims Act Allegations Relating To Medically Unnecessary Inpatient Behavioral Health Services And Illegal Kickbacks

Universal Health Services, Inc., UHS of Delaware, Inc.(together, UHS), and Turning Point Care Center, LLC (Turning Point), a UHS facility located in Moultrie, Georgia, have agreed to pay a combined total of $122 million to resolve alleged violations of the False Claims Act for billing for medically unnecessary inpatient behavioral health services, failing to provide adequate and appropriate services, and paying illegal inducements to federal healthcare beneficiaries, the Department of Justice announced today. UHS owns and provides management and administrative services to nearly 200 acute care inpatient psychiatric hospitals and residential psychiatric and behavioral treatment facilities nationwide. UHS is headquartered in King of Prussia, Pennsylvania.

As part of a comprehensive civil settlement, UHS will pay the United States and participating states a total of $117 million to resolve allegations that its hospitals and facilities knowingly submitted false claims for payment to the Medicare, Medicaid, TRICARE, Department of Veterans Affairs, and Federal Employee Health Benefit programs for inpatient behavioral health services that were not reasonable or medically necessary and/or failed to provide adequate and appropriate services for adults and children admitted to UHS facilities across the country.

In a separate civil settlement, Turning Point will pay the United States and the State of Georgia $5 million to resolve allegations that it provided free or discounted transportation services to induce Medicare and Medicaid beneficiaries to seek treatment at Turning Point’s inpatient detoxification and rehabilitation program or intensive outpatient program.

“The Department of Justice is committed to protecting patients and taxpayers by ensuring that the treatment provided to federal healthcare beneficiaries is reasonable, necessary, and free from illegal inducements,” said Acting Assistant Attorney General Ethan P. Davis for the Department of Justice’s Civil Division. “The Department will continue to be especially vigilant when vulnerable patient populations are involved, like those served by behavioral healthcare providers.”

The government alleged that, between January 2006, and December 2018, UHS’s facilities admitted federal healthcare beneficiaries who were not eligible for inpatient or residential treatment because their conditions did not require that level of care, while also failing to properly discharge appropriately admitted beneficiaries when they no longer required inpatient care. The government further alleged that UHS’s facilities billed for services not rendered, billed for improper and excessive lengths of stay, failed to provide adequate staffing, training, and/or supervision of staff, and improperly used physical and chemical restraints and seclusion. In addition, UHS’s facilities allegedly failed to develop and/or update individual assessments and treatment plans for patients, failed to provide adequate discharge planning, and failed to provide required individual and group therapy services in accordance with federal and state regulations.

Of the $117 million to be paid by UHS to resolve these claims, the federal government will receive a total of $88,124,761.27, and a total of $28,875,238.73 will be returned to individual states, which jointly fund state Medicaid programs.

“Quality mental health treatment is critical for the patients who place their trust in the hands of service providers,” said William M. McSwain, United States Attorney for the Eastern District of Pennsylvania. “The allegations involved in this matter — inappropriate billing and inadequate care – have no place in our health care system. Behavioral health service entities must have strong mechanisms in place, including appropriate supervision and oversight, to avoid fraud and abuse in order to ensure they provide the level of care that their patients deserve.”

With respect to Turning Point, the government alleged that, from January 2007 until May 1, 2019, the facility provided free or discounted transportation services to Medicare and Medicaid beneficiaries to induce them to seek detoxification and rehabilitation treatment at Turning Point’s inpatient or intensive outpatient programs.

“Illegal inducements should never play a role in a patient’s decision regarding treatment, especially when a patient is seeking care for addiction and other behavioral health needs,” said Byung J. “BJay” Pak, U.S. Attorney for the Northern District of Georgia. “Our office remains committed to pursuing unlawful arrangements that undermine the integrity of federal healthcare programs.”

The government’s settlement with UHS resolves 18 cases pending in the Eastern District of Pennsylvania, Western District of Michigan, the Eastern District of Michigan, and Northern District of Georgia under the qui tam, or whistleblower, provision of the False Claims Act, which permit private parties to file suit for false claims on behalf of the United States and to share in any recovery. The whistleblower share of the federal portion of the settlement will be $15,862,457.03. The settlement with Turning Point resolves an additional qui tam lawsuit filed in the Northern District of Georgia. The whistleblower in that suit will receive $861,853.64, from the federal share of the Turning Point settlement.

“Providing top quality health care to service members and their beneficiaries is the primary mission of the Defense Health Agency. It’s unfortunate a company tried to take advantage of a system that ensures health care for those men and women who are on the front lines every day protecting our nation,” said Lt. Gen. Ronald Place, director, DHA. “We commend the Department of Justice and its partners for bringing justice to those responsible for knowingly defrauding TRICARE beneficiaries.”

“VA OIG continues to be vigilant in holding those accountable who defraud VA programs and ensure that tax payer dollars are appropriately utilized for the care of our nation’s veterans and their dependents. Also, we thank our law enforcement partners and the United States Attorney’s Office for their support,” said Acting Special Agent in Charge Jeffrey Stachowiak, Department of Veterans Affairs, Office of Inspector General.

“The OPM OIG does not tolerate predatory behavior that risks the health and safety of vulnerable patients,” said Thomas W. South, Deputy Inspector General for Investigations for the Office of Personnel Management. “We are grateful for the fine work of our investigators and Department of Justice partners. Today’s settlement demonstrates OPM-OIG’s unwavering commitment to investigating conduct that affects vulnerable FEHBP enrollees.”

Contemporaneous with the civil settlements announced today, UHS, on behalf of its inpatient acute and residential behavioral health facilities, has entered into a Corporate Integrity Agreement with the U.S. Department of Health and Human Services, Office of Inspector General (OIG), which will remain in effect for five years. UHS must retain an independent monitor, selected by the OIG, which will assess UHS’s Behavioral Health Division’s patient care protections and report to the OIG. In addition, an independent review organization will perform annual reviews of UHS’s inpatient behavioral health claims to federal health care programs.

“Protecting the health and safety of Medicare and Medicaid patients is one of our primary concerns. Our Corporate Integrity Agreement provides future protection for patients and federal health care programs through controls and monitoring designed to ensure that UHS’s behavioral health facilities provide quality services and medically necessary care to patients,” said Gregory E. Demske, Chief Counsel to the Inspector General for the United States Department of Health and Human Services. “This case demonstrates that the government will aggressively pursue allegations of substandard inpatient care.”

The settlement with UHS was the result of a collaborative effort among numerous federal and state agencies. The Commercial Litigation Branch of the Department of Justice’s Civil Division and the U.S. Attorney’s Office for the Eastern District of Pennsylvania handled the cases, with substantial assistance from the U.S. Attorneys’ Offices for the Middle District of Florida, the Northern District of Georgia, the Eastern District of Michigan, the Western District of Michigan, the Middle District of Georgia, the Northern District of Illinois, the Middle District of North Carolina, the Western District of North Carolina, the District of Oregon, the Middle District of Pennsylvania, the Southern District of Texas, the District of Utah, the Eastern District of Virginia, the Western District of Virginia, the Northern District of Oklahoma, and the District of Wyoming, as well as the National Association of Medicaid Fraud Control Units (NAMFCU). The Civil Division and NAMFCU coordinated the nationwide investigation of UHS in partnership with the Office of Inspector General for the Department of Health and Human Services; the Department of Defense Criminal Investigative Service; the Department of Veterans Affairs, Office of Inspector General; the Office of Personnel Management, Office of Inspector General; and the Federal Bureau of Investigation. The Civil Division’s Commercial Litigation Branch and the U.S. Attorney’s Office for the Northern District of Georgia handled the Turning Point matter with assistance from the Office of Attorney General of Georgia and the Office of Inspector General for the U.S. Department of Health and Human Services.

The civil settlement with UHS resolved the following captioned cases: United States ex rel. Gardner v. Universal Health Services, Inc., 2:17-cv-03332-AB (E.D. Pa.); United States ex rel. Naylor v. Universal Health Services, Inc., 2:14-cv- 06198-AB (E.D. Pa.); United States ex rel. Jain v. Universal Health Services, Inc., et al., No. 2:13-cv-06499-AB (E.D. Pa.); United States ex rel. Chisholm v. Universal Health Services, Inc., et al., 2:17-cv-01892-AB (E.D. Pa.); United States ex rel. Doe, et al. v. Universal Health Services, Inc., et al., No. 2:14-cv-00921 (E.D. Pa.); United States ex rel. Pate v. Behavioral Hospital of Bellaire, et al., 2:15-cv-00554-AB (E.D. Pa.); United States ex rel. Brinson, et al. v. Universal Health Services, Inc., et al., 2:14-cv-07275-AB (E.D. Pa.); United States ex rel. Mitchell v. Turning Point Care Center, Inc., et al., 2:15-cv-00259-AB (E.D. Pa.); United States ex rel. Peterson v. Universal Health Services, Inc., et al., 2:17-cv-01897-AB (E.D. Pa.); United States ex rel. Conaway, et al. v. Universal Health Services, Inc., et al., 2:17-cv- 02233-AB (E.D. Pa.); United States ex rel. Eborall v. Universal Health Services, Inc., et al., 2:17-cv-03249-AB (E.D. Pa.); United States ex rel. Sachs, et al. v. Universal Health Services, Inc., et al., 2:17-cv-03604-AB (E.D. Pa.); United States ex rel. Klotz v. Universal Health Services, Inc., et al., 2:17-cv-05163-AB (E.D. Pa.); United States ex rel. Brockman, et al. v. Universal Health Services, Inc., et al., 2:17-cv-05350-AB (E.D. Pa.); United States ex rel. Glass v. Hughes Center, LLC., et al., 2:18-04018-AB (E.D. Pa.); United States ex rel. Parent-Leonard v. Forest View Psychiatric Hospital, et al., No. 1:18-cv-1426 (W.D. Mich.); United States ex rel. Russell, et al. v. Universal Healthcare Services, Inc., et al., No. 1:19-CV-0764 (N.D. Ga.); United States ex rel. McLauchlin, et al. v. Havenwyck Holdings, Inc., et al., No. 2:19-cv-10832 (E.D. Mich.).

The settlement with Turning Point resolved the case captioned United States ex rel. Heatley v Turning Point Care Center LLC, et al., 1:17-cv-3869-AT (N.D. Ga.).

The claims resolved by the settlements are allegations only, and there has been no determination of liability.



Civil Division

Press Release Number:

20-649 & Mike Bothwell Lawfirm does not claim or imply ownership of this article. 

Hospice to pay $1.75 million to resolve false claims act allegations

The USDJ Northern District recently published the below. See a portion below: 

ATLANTA – STG Healthcare of Atlanta, Inc. (“STG Healthcare”) and two of its senior executives, Paschal “Pat” Gilley and Mathew Gilley, have agreed to pay $1.75 million to resolve allegations that STG Healthcare, operating as Interim Healthcare of Atlanta, submitted or caused the submission of false claims to Medicare and Medicaid for patients who were not eligible for the hospice benefit and that resulted from STG Healthcare’s provision of unlawful payments to a referring physician in violation of the Anti-Kickback Statutes.

“Hospice is not a blank check for unscrupulous medical providers willing to admit patients who are not terminally ill,” said U.S. Attorney Byung J. “BJay” Pak.  “It is reserved for those who truly need it.  We will also continue to prioritize cases where it appears that a medical decision, especially the decision to forego curative treatment, has been influenced by a kickback.”

“When healthcare providers put their financial interests above the needs of patients the federal funds are diverted from where they are truly needed, putting our most vulnerable citizens at risk,” said Chris Hacker, Special Agent in Charge of FBI Atlanta. “The message is clear; the FBI will not tolerate companies who file false claims to generate more corporate revenue and take advantage of programs like Medicare & Medicaid.”

“As more Americans choose hospice care, more government funding is being provided to this critical service. Unfortunately, scammers are seizing an opportunity to steal precious funding by enrolling ineligible patients in hospice care,” said Derrick Jackson, Special Agent in Charge for the Office of Inspector General of the U.S. Department of Health and Human Services.  “With our law enforcement partners, we will continue to protect patients and the programs on which they depend.”

“The hospice benefit provided by Medicaid is especially reserved for terminally ill Georgians at a critical time of transition in their care,” said Attorney General Chris Carr.  “Our office is proud to have worked alongside the U.S. Attorney’s Office for the Northern District of Georgia in this effort, and we will continue to ensure the hospice benefit is not exploited and abused by health care providers to the detriment of Georgia taxpayers.”

The Medicare and Medicaid hospice benefit is available for patients who elect palliative treatment (medical care focused on providing patients with relief from pain, symptoms, or stress) for terminal illness and who have a life expectancy of six months or less if their illness runs its normal course.  Before billing government healthcare programs, a hospice provider must comply with Medicare and Medicaid’s requirements and ensure that patients who are foregoing curative care are in need of end-of-life care. & Mike Bothwell Lawfirm does not claim or imply ownership of this article. 

Full article link here:

Justice Department Recovers over $3 Billion from False Claims Act Cases in Fiscal Year 2019

Justice department logo

The United States Justice Department recently published the below article. See a portion below: 

The Department of Justice obtained more than $3 billion in settlements and judgments from civil cases involving fraud and false claims against the government in the fiscal year ending Sept. 30, 2019, Assistant Attorney General Jody Hunt of the Department of Justice’s Civil Division announced today.  Recoveries since 1986, when Congress substantially strengthened the civil False Claims Act, now total more than $62 billion.

“The significant number of settlements and judgments obtained over the past year demonstrate the high priority this administration places on deterring fraud against the government and ensuring that citizens’ tax dollars are well spent,” said Assistant Attorney General Hunt.  “The continued success of the department’s False Claims Act enforcement efforts are a testament to the tireless efforts of the civil servants who investigate, litigate, and try these important cases as well as to the fortitude of whistleblowers who report fraud.”

Of the more than $3 billion in settlements and judgments recovered by the Department of Justice this past fiscal year, $2.6 billion relates to matters that involved the health care industry, including drug and medical device manufacturers, managed care providers, hospitals, pharmacies, hospice organizations, laboratories, and physicians.  This is the tenth consecutive year that the department’s civil health care fraud settlements and judgments have exceeded $2 billion.  The amounts included in the $2.6 billion reflect only federal losses, but in many of these cases the department was instrumental in recovering additional millions of dollars for state Medicaid programs.

In addition to combating health care fraud, the False Claims Act serves as the government’s primary civil tool to redress false claims for federal funds and property involving a multitude of other government operations and functions.  The Act helps to protect our military and first responders by ensuring that government contractors provide equipment that is safe, effective, and cost efficient; to protect American businesses and workers by promoting compliance with customs laws, trade agreements, visa requirements, and small business protections; and to protect other critical government programs ranging from the provision of disaster relief funds to farming subsidies.

In 1986, Congress strengthened the 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 percent.  Whistleblowers filed 633 qui tam suits in fiscal year 2019, and this past year the department recovered over $2.1 billion in these and earlier filed suits.

Health Care Fraud

The department investigates and resolves matters involving a wide array of health care providers, goods, and services.  The department’s health care fraud enforcement efforts not only recover money for federal health care programs, such as Medicare, Medicaid, and TRICARE, but also help deter fraud schemes that put patients at risk and increase health care costs.

Reflecting the department’s commitment to holding drug companies accountable for their role in the opioid crisis, two of the largest recoveries involving the health care industry this past year came from opioid manufacturers.  In one matter, as part of a global resolution of criminal and civil claims, Insys Therapeutics paid $195 million to settle civil allegations that it paid kickbacks to induce physicians and nurse practitioners to prescribe Subsys for their patients.  The kickbacks allegedly took the form of sham speaker events, jobs for the prescribers’ relatives and friends, and lavish meals and entertainment.  The government also alleged that Insys improperly encouraged physicians to prescribe Subsys for patients who did not have cancer, and lied to insurers about patients’ diagnoses to ensure payment by federal healthcare programs.  In another matter, Reckitt Benckiser Group plc paid a total of $1.4 billion to resolve criminal and civil liability related to the marketing of the opioid addiction treatment drug Suboxone, which is a formulation of the opioid buprenorphine.  As part of the resolution, RB Group paid $500 million to the United States to resolve civil allegations that it directly or through subsidiaries promoted Suboxone to physicians who were writing prescriptions for uses that were unsafe, ineffective, and medically unnecessary; promoted Suboxone Film using false and misleading claims that it was less susceptible to diversion, abuse, and accidental pediatric exposure than other buprenorphine products; and took steps to delay the entry of generic competition in order to improperly control pricing of Suboxone.

The department also pursued other cases involving drug manufacturers.  For example, Avanir Pharmaceuticals paid over $95 million to resolve allegations that it paid kickbacks and engaged in false and misleading marketing to induce healthcare providers in long term care facilities to prescribe the drug Neudexta for behaviors commonly associated with dementia patients, which is not an approved use of the drug.  The department also continued to investigate efforts by drug manufacturers to facilitate increases in drug prices by funding the co-payments of Medicare patients.  Congress included co-pay requirements in the Medicare program, in part, to serve as a check on health care costs, including the prices that pharmaceutical manufacturers can demand for their drugs.  This year, seven drug manufacturers – Actelion Pharmaceuticals US Inc., Amgen Inc., Astellas Pharma US Inc.Alexion Pharmaceuticals, Inc., Jazz Pharmacueticals Inc., Lundbeck LLC, and US Worldmeds LLC – paid a combined total of over $624 million to resolve claims that they illegally paid patient copays for their own drugs through purportedly independent foundations that the companies in fact treated as mere conduits.

The department also reported substantial recoveries involving a variety of other healthcare providers.  Pathology laboratory company Inform Diagnostics, formerly known as Miraca Life Sciences Inc., paid $63.5 million to resolve allegations that it paid kickbacks to referring physicians in the form of subsidies for electronic health records (EHR) systems and free or discounted technology consulting services.  Greenway Health LLC, an EHR software vendor, paid over $57 million to resolve allegations that it misrepresented the capabilities of its EHR product “Prime Suite” and provided unlawful remuneration to users to induce them to recommend Prime Suite to prospective new customers.  Encompass Health Corporation (formerly known as HealthSouth Corporation), the nation’s largest operator of inpatient rehabilitation facilities (IRFs), paid $48 million to resolve allegations that some of its IRFs provided inaccurate information to Medicare to maintain their status as an IRF and to earn a higher rate of reimbursement, and that some admissions to its IRFs were not medically necessary.

Recoveries in Whistleblower Suits

Of the $3 billion in settlements and judgments reported by the government in fiscal year 2019, over $2.1 billion arose from lawsuits filed under the qui tam provisions of the False Claims Act.  During the same period, the government paid out $265 million to the individuals who exposed fraud and false claims by filing these actions.

The number of lawsuits filed under the qui tam provisions of the Act has grown significantly since 1986, with 633 qui tam suits filed this past year – an average of more than 12 new cases every week.

“Whistleblowers continue to play a critical role identifying new and evolving fraud schemes that might otherwise remain undetected,” said Assistant Attorney General Hunt.  “Taxpayers have benefitted greatly from these individuals who are often required to make substantial sacrifices to bring these schemes to light.”

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 also included in the False Claims Act authority for the government to dismiss cases that do not advance the goal of fraud prevention, and during the past year the government made increasing use of this tool to help prioritize and protect the expenditure of government resources.

Finally, Assistant Attorney General Hunt expressed appreciation for the many dedicated public servants throughout the department’s Civil Division and the U.S. Attorneys’ Offices, as well as the agency Offices of Inspector General and the many other federal and state agencies that contributed to the department’s False Claims Act recoveries this past fiscal year.

“The accomplishments announced today reflect the extraordinary efforts of the men and women throughout the government committed to protecting the federal fisc and the integrity of the government’s programs,” said Assistant Attorney General Hunt.  “Having served many years in the Civil Division, I have witnessed the passion and dedication of the talented employees who have committed their careers to serving the American people and defending the interests of our great nation.” & Mike Bothwell Lawfirm does not claim or imply ownership of this article. Full article link here:

Trump & our thoughts on why we should protect Whistleblowers

USA Today recently published the following article “Trump’s allies want to ID the whistleblower, who may learn the price of speaking out“.

Here are our my thoughts.

Shortly after signing the Declaration of Independence, the Continental Congress passed a resolution for whistleblower protection.  Some sailor and marines blew the whistle on a commander of the navy during the war with Great Britain.  They reported the problems to the Continental Congress and were prosecuted for it.  The Continental Congress not only passed the resolution supporting blowing the whistle on such abuse (calling it a “duty”), but it passed a subsequent resolution to pay the costs of their defense.

Another major whistleblower legislation was passed in 1863 during the Civil War.  The False Claims Act also known as the Lincoln Law allowed private citizens to sue on behalf of the government to recover for false claims and fraud against the government.  This law was significantly revised in 1985 and has become the government’s number one tool for prosecuting fraud against the United States.  Whistleblowers recover from 15% to 30% of what the government receives and cases under the False Claims Act have brought in $60 billion since it was revamped in 1985.

Various state and federal agencies have passed whistleblower protections and evinced a consensus that whistleblowers play a crucial role in ferreting out fraud, waste, and abuse in our system.  In 1985, when Congress was considering one of the oldest and most robust whistleblower statutes (the False Claims Act), it noted that the act was underutilized in large part because of fear of retaliation.  That is perhaps the number one deterrent to people shinning a light on corruption and illicit dealings.  From July 30, 1778 to the present, America has agreed to protect people who are willing to bring bad things to light.

We absolutely need to continue this protection. I’m fighting for this daily.

Beaumont To Pay $84.5 Million To Settle False Claims Act In Federal Whistleblower Case

Bothwell Law Group filed a case that aided whistleblowers in the reporting of fraudulent activity by William Beaumont Hospital in Detroit, Michigan. The hospital agreed to pay an $84.5 million settlement to resolve allegations under the False Claims Act of improper relationships with eight referring physicians that led to the submission of false claims to the Medicare, Medicaid and the military Tricare programs.

Federal Whistleblower Attorney

If you have witnessed misuse, fraud or waste of government funds and feel compelled to do something about it, contact us at Bothwell Law Group at 770-643-1606.

Settlement Press Releases:

Setting Expectations When It Comes to False Claims Settlements

What can you expect with false claims settlements? Here are some points to ponder.

false claims settlementsThere are provisions found in the False Claims Act that make it possible to file suit and seek false claims settlements. If you’re considering blowing the whistle for false claims you are aware of it’s important that your expectations are realistic.

Experienced attorneys strive to set reasonable expectations with their clients and help them understand what could come to pass. Here is some basic information you should know about why defendants would be willing to settle and what could happen if there is a settlement.

Reasons Providers Settle Instead of Fighting Suits

Physicians, hospitals, hospice centers, and nursing homes may choose to settle a false claim lawsuit for many reasons. Some of the most common are:

  • Minimize legal fees: The legal costs related to fighting the claim may be prohibitive. If the case continues for a long time, those fees could be more than the amount of the original suit. When that is a real possibility, settling now translates into lower legal fees.
  • Reduce the amount paid to Medicare and/or the plaintiff: Defending against a lawsuit and ultimately losing does mean the risk of paying a higher figure to the plaintiff or repaying a more substantial sum to Medicare. In many cases, it would be both. When the parties who filed the suit are willing, negotiating a settlement could result in paying a much smaller amount.
  • Avoid negative publicity: Reputation is essential in the health care field. If word gets around that someone has intentionally falsified claims it could take years to undo the damage. Quickly and quietly settling contains the potential damage and makes a public relations disaster less likely.
  • No admission of guilt: The terms of many settlements exclude any requirement for the provider to admit guilt. That’s important, as it minimizes the risks of losing the license to practice or to operate a facility.
  • A matter of time: A settlement may be the best solution just because of the time involved. Next to the financial resources needed to fight the suit, allocating time for this action means less time to generate revenue or keep the facility or practice going.

Whatever the reason is for settling, the decision to settle impacts the plaintiff. The degree of that impact depends on what happens next.

Terms and Provisions within False Claim Settlements

Every settlement associated with a false claims lawsuit will include specific provisions. Those terms relate to the plaintiff as well as the defendant. Depending on the nature of the claim and the original amount sought, the terms and provisions may or may not include specific actions that one or both parties agree to observe.

The terms of payment are one example. In some cases, the plaintiff agrees to pay the settlement amount by a specific date. They can pay the sum in a series of installments leading up to the due date or pay the entire amount at one time. Depending on the number of plaintiffs, a trustworthy third party receives the payments and disburses the funds based on an approved schedule.

The plaintiff may agree to refrain from taking any further legal action against the defendant. The wording on this provision must be exact. A broad provision could prevent the plaintiff from pursuing action related to the same plaintiff but for a different cause. That includes claims prosecuted under laws other than the False Claims Act.

Sealing the terms of the settlement is another common approach. With this particular provision, the plaintiff and the defendant agree to not reveal the details of the settlement or talk about the case in anything other than the broadest terms. The goal is often to protect the privacy of all parties involved in the original suit.

The Bottom Line:  What about the Compensation?

What can you expect in the way of compensation? The plaintiff may agree to pay all legal fees, including the funds owed to your legal counsel. That’s good news since the plaintiff has no legal fees to pay.

In terms of how much the plaintiff may receive, a lot depends on whether a federal agency is among the relators and the degree of agency involvement. When the suit does not include a government entity, the relator who launched the lawsuit is by law allowed to receive somewhere between 15% and 25% of the settled amount. The remainder goes to Medicare.

Whistleblowers who pursue a case after the government chooses not to act may receive somewhere between 25% and 30% of the settlement amount. A writ of qui tam makes this possible. The private citizen comes forth with information and assists in pursuing a case of false Medicare claims issued by a health care provider.

Do you have some involvement with a claim you believe to be false? Contact the Bothwell Law Group online and get more information about false claims settlements and what to expect.

What Are the Success Rates of False Claims Act Cases?

Find out why success rates of false claims act cases remain high.

Success Rates of False Claims Act CasesThe success rates of False Claims Act cases have been on the rise for the past decade. Unfortunately, as financial rewards grew, so did the number of nuisance cases. The government spends money whenever they investigate an FCA lawsuit, so eventually, the Department of Justice asked prosecutors to assess cases more diligently. Specifically, they chose to place emphasis on the right to file for dismissal of certain lawsuits to avoid unnecessary costs.

The goal of a memo released in January 2018 by Michael Granston, the director of the Commercial Civil Fraud Division of the DOJ, was to reduce government waste and conflicts associated with FCA litigation. Once public, the Granston Memo created the impression the government would not be as supportive of FCA cases as it had been in the recent past. The memo caused worry the lawsuits weren’t as likely to be successful. Thankfully, that isn’t how things have played out in practice.

Hundreds of Cases, a Handful of Dismissals

When a whistleblower files a lawsuit, government agencies assess the case to see if they should intervene. It’s beneficial when a government agency joins a case. It brings a tremendous number of resources to the table. Whistleblowers usually have the choice to continue the case on their own if the government refuses. There is one exception: 31 U.S. Code § 3730(c)(2)(A).

The law allows for the government to file for a dismissal of a case when it meets specific guidelines. Lawsuits have clarified when these requests are appropriate. Namely, they must pertain to:

  • Meritless or opportunistic qui tam cases
  • Lawsuits that would interfere with federal policies and procedures
  • Lawsuits that would interfere with existing cases initiated by the government

Over the year, as whistleblowers filed more than 700 qui tam lawsuits, the government sought to dismiss only a handful. Most recently, the government sought to dismiss 11 cases, all filed by the same plaintiff, which claimed preauthorization of prescriptions and patient education materials supplied by pharmaceutical companies amount to illegal kickbacks.

These are helpful resources which help patients enjoy a safer, higher quality of care, and federal regulations require them in some cases. It was right for the government to intervene. Not only did the decision save money, but it protected the rights and safety of patients and the efficiency of existing healthcare programs. It’s obvious the memo has not created a wave of dismissal requests as some feared.

However, finding a lawyer experienced in the type of FCA case you want to file is more important than ever. You’ll need to be able to follow the letter of the law, and each type of violation has its own specifics.

Success Rates for Qui Tam Cases Remain High

According to data tabulated by Taxpayers Against Fraud, approximately 80 percent of FCA cases are qui tam suits. The overwhelming majority result in monetary settlements, awards, or restrictions for companies.

In one of the first cases of the new year, the pharmacy giant, Walgreens, reached a historic agreement with the government in a prescription billing scheme reported by an employee. The whistleblower in that case will receive 21 percent of a record-breaking $60 million settlement.

Together, the lawsuits recovered over $3.7 billion in federal funds last year – the eighth year in a row where awards have capped $3 billion – and qui tam suits recovered more, on average, than those the government waged on its own. In 2017, cases where the government declined to intervene resulted in awards of $426 million.

Despite the Granston Memo, FCA cases remain one of the most effective means of fraud detection in government spending. That’s true in large part to qui tam provisions which reward individuals financially for filing suit. Since 1986, whistleblowers involved in qui tam suits have collected more than $6.5 billion.

That’s different from saying anyone who files a lawsuit is going to cash in. Before taking up a cause, it’s important to work with a lawyer who can accurately assess your chances of winning and research whether or not the government will have cause to try to dismiss your case.

What Do We Need for the Laws to Change?

President Lincoln passed the FCA with the help of Congress in the 1800s. Fraudsters took advantage of Civil War funding without delivering on their promises. As a result, soldiers starved and froze to death without adequate supplies. The war was long, and the lack of reliable supplies led to significant losses on both sides. Legislators couldn’t ignore it.

In the 1940s, Congress revisited the FCA, making changes to the law which severely limited the benefits and benefits it would provide. Corruption soared again until, in the 1980s, Congress dealt with massive misspending within the Department of Defense.

These days, it’s used mostly to protect people against healthcare fraud. Legislators know these cases aren’t just saving money. They’re saving lives. It’s doubtful they’ll limit the reach of the FCA anytime soon. However, there are higher expectations placed on lawyers who try these cases.

Finding the right person for the job is more important to your success than ever. You’ll find the team you need by contacting the skilled FCA case attorneys at Bothwell Law Group by clicking or calling 770.643.1606 today.

What Is the False Claims Act and How Does It Affect Medicaid?

Learn how the False Claims Act and Medicaid work in tandem.

the False Claims ActThe False Claims Act is well-suited to deal with current Medicaid problems. Surprisingly, the law came out of the Civil War to combat other types of government fraud. The principles still hold true today. Furthermore, the government uses them more often to prosecute businesses and individuals who attempt to defraud the government’s healthcare system.

History of the False Claims Act

While many people think of whistleblowers as a construct of the 20th century, there have always been people willing to risk it all for the greater good. Instead of expecting them to sacrifice their livelihood to ensure the safety and security of the masses, politicians decided early on these people should have special protection.

The False Claims Act is also called the “Lincoln Law.” Abraham Lincoln, the 16th U.S. President, enacted the law in 1863 to stop corruption during the Civil War. The leading minds of the time couldn’t fathom corrupt individuals living high on the hog when boys were fighting with the barest essentials.

The passing of the False Claims Act was a pivotal moment in U.S. history where the country distinguished itself and its values in a way many have forgotten today. Fortunately, the law holds and serves to protect individuals who speak out in an effort to keep the country’s resources from going to waste.

What about Qui Tam Lawsuits?

The act introduced “qui tam” lawsuits, allowing private individuals to sue those defrauding the government on the nation’s behalf. At the time, whistleblowers (known as “relators”) received half of the damages assessed by the courts. That changed in 1943, which had a drastic impact on the number of false claims reported. It also restricted qui tam eligibility to cases where the government had previous information, even when the relator was the source.

The 1940s revisions to the False Claims Act left the legislation virtually impotent against government corruption. Over the next 40 years, the gaps the changes left in accountability created a widespread problem, particularly in regard to defense contracts. During the Reagan Administration, the military came under fire for paying exorbitant amounts of money for basic items.

Scores of contractors were suspect, but investigators ran into brick walls — or rather, walls of employees too afraid to talk. Congress worked diligently to rework the False Claims Act to make whistleblowing more enticing, providing job protection, regranting qui tam eligibility for individuals who had previously informed the government of the fraud and ensuring relators received 15 – 30 percent of judgments. It’s working.

In 2015, the Department of Justice awarded a whistleblower nearly $2 million in a judgment against a children’s hospital that misstated the number of beds it had available in order to qualify for grant funding. Between repayment, penalties and fines, the government reclaimed $12.9 million.

Using the False Claims Act to Fight Medicaid Fraud Today

Medicaid is a federal and state healthcare program for low-income individuals and those with disabilities. It covers approximately 74 million people in the U.S. The complicated structure of the program leaves it ripe for fraud and other types of correction.

The most common types of Medicaid fraud committed by facilities, organizations and healthcare providers include:

  • Performing unnecessary procedures
  • Billing for procedures never performed
  • Writing unnecessary prescriptions
  • Using improper billing codes to increase fees
  • Offering referral fees or kickbacks
  • Knowingly treating the wrong person
  • Knowingly treating someone who shouldn’t qualify

The most common types of Medicaid fraud committed by patients include:

  • Providing false information on Medicaid applications
  • Altering prescriptions or requesting unnecessary medication for resale
  • Taking money from a facility or professional in exchange for unnecessary services
  • Using multiple Medicaid cards under false identities
  • Loaning Medicaid cards to those who don’t qualify for coverage

As you can see, in certain situations an individual would be able to file a suit against any number of players in the Medicaid fraud game. The Department of Justice is going after the biggest offenders, and they’re winning big.

In April, for instance, the DOJ won an $18 million settlement against Banner Health after an investigation showed four hospitals regularly provided unnecessary treatment for patients in order to increase their Medicaid bills. A whistleblower received over $3 million in the case and helped stamp out corruption that ultimately robs people of the care they deserve.

Do you have proof of Medicaid fraud? Speak out before someone else beats you to the punch.

Contact the skilled False Claims Act-Medicaid attorneys at Bothwell Law Group by clicking or calling 770.643.1606 today. We are here to help you consider your best legal options moving forward.

Why Are Medicare False Claims Cases on the Rise?

The instances of using the False Claims Act in Medicare cases are going up.

false claimsGiven its size and the amount of money at stake, Medicare has enormous potential for fraud and false claims. So it’s no wonder that the False Claims Act is a popular law to crack down on Medicare fraud. But what is the False Claims Act and why are Medicare fraud claims rising? Keep reading to get the scoop.

The False Claims Act

The False Claims Act is a federal law that fights fraud against the federal government. It imposes hefty fines on those who are responsible for improperly taking the government’s money. It also allows individuals, called relators, to bring civil lawsuits against those who commit fraud. These civil lawsuits are “qui tam actions” and enable relators not just to sue the responsible parties, but receive a reward for their efforts.

Depending on the facts of the case, such as the level of involvement of the relator in the qui tam action, a relator may recover anywhere from 10 to 30 percent of the total amount of money the government can recover. Most of the time, it will be around 15 or 20 percent. Thirty percent recovery is for situations where the relator has to do a lot of work, such as bringing the qui tam lawsuit without government assistance. Ten percent is more common when the relator had some involvement in the fraud. It sounds unfair to reward someone engaging in fraud, but the government understands that without these whistleblowers, the scam would continue. The government also knows that those involved in the fraud often serve as the most effective whistleblowers.

Besides rewarding whistleblowers, the False Claims Act can levy potentially millions of dollars in monetary penalties on those who commit fraud. For example, someone guilty of violating the False Claims Act can pay around $10,000 for each fraudulent act. So a doctor’s office that improperly bills Medicare 100 times doesn’t pay $10,000 in damages. Instead, it pays $1 million, or $10,000 for each fraudulent bill sent to Medicare.

Increasing Medicare Fraud

Why are the instances of Medicare Fraud going up? There are several reasons for this.

First, people are getting smarter in finding ways to defraud the government. Medicare is a relatively old program, starting back in the 1960s. This provides plenty of time and opportunity for unscrupulous individuals to find ways to steal money from the government. With such a complex government program, there are many ways fraud can occur.

One of the more popular methods is to use kickbacks. Kickbacks are special arrangements where one party will get money for providing an improper benefit to another. In the healthcare context, kickbacks often take place when one doctor sends a patient to another doctor in return for a cash payment. This cash payment is a kickback.

Another form of Medicare fraud is upcoding. With upcoding, medical offices use the wrong code on a bill to receive more money than necessary. So instead of using a billing code for a medical service worth $5,000, a code for a service worth $15,000 goes on the bill.

Fake Medicare Patients

Then there’s there use of fake patients. In this scenario, a doctor or hospital may completely make up patients to bill for nonexistent services. A hospital might bill Medicare for John Smith’s X-ray during last month’s emergency room visit even though there was no such visit and John Smith doesn’t exist. A slight variation of this scheme is when the patient exists, but the medical service does not. Perhaps there was a real John Smith that came into the emergency room, but he never got an x-ray, just a physical exam, which might be much cheaper.

Second, the overall population in the United States continues to age. As people get older, they require more medical services. This provides more opportunities for individuals in the healthcare industry to commit fraud. It’s a lot easier to defraud more money from the government when a doctor has 80 patients instead of 60. Even if the rate at which Medicare fraud occurs goes down, the total number of fraudulent occurrences may rise as a result of this growth in the use of Medicare.

Third, there is the passage of the Affordable Care Act, also known as “Obamacare.” This law made massive changes to the legal framework of the healthcare industry. One thing it did was take steps to cut down on Medicare fraud. Changes to Medicare to stop fraud include harsher penalties, sharing of information between state and federal agencies and more oversight. With closer scrutiny and additional attempts to reduce fraud, it’s no surprise when regulators and potential whistleblowers find more issues. So even though the amount of reported fraud rises, it may be due in part because people are just paying more attention.

Want to Discover More about Stopping Medicare Fraud?

Find out more about Medicare false claims by contacting our legal team at Bothwell Law Group online.

How a False Claims Settlement Makes Its Way Through the Courts

Getting a False Claims settlement is nice, but it often requires going through the court system.

False Claims SettlementThe False Claims Act is a powerful tool to stop fraud, but getting a False Claims settlement as a relator can be a very lengthy and involved process. This settlement usually comes as a result of someone going through the qui tam process. The purpose of this blog post is to explain what a qui tam case is and the major steps involved.

What Is a Qui Tam Action?

A qui tam action is a type of civil lawsuit where a relator (who is the whistleblower) sues someone or an organization that commits fraud against the federal government. The relator brings this lawsuit on behalf of the government and in return is eligible to receive a monetary award. This award varies but can range from anywhere from 15 percent to 30 percent of the money they can help recover. The exact percentage depends on how much work they provide in recovering the money for the federal government.

This percentage will drop if the relator takes part in the fraud. It might seem unfair that someone committing fraud can profit from it, but it is better that the federal government gets 85 cents on the dollar rather than zero cents on the dollar.

Getting an Attorney

If a whistleblower wants to become a relator, they must hire an attorney. This seems a bit odd since a criminal defendant facing decades behind bars can choose to represent themselves at the criminal trial. But the difference here is that in a qui tam action, the whistleblower is a relator, which means they bring a lawsuit on behalf of the federal government. Because it’s ultimately the federal government’s lawsuit, they decide on whether they want an attorney – and they always have an attorney.

So to bring a qui tam lawsuit as a relator, an individual must hire an attorney. The individual needs to hire a lawyer who has experience and knowledge in qui tam lawsuits. They are unlike any other civil or criminal court case, so a prospective relator doesn’t want an attorney to learn as the case goes along. They need experience right out of the gate.

Starting the Qui Tam Action

The qui tam lawsuit process officially begins when the relator files a complaint in federal court. The one unique thing about this complaint is that it is “under seal,” which means in secret. This means the defendant in the case has no idea it is now the defendant in a lawsuit. This secrecy is essential to prevent the defendant from hiding or destroying evidence or fleeing the country. It also helps protect the relator from potential retaliation because it allows them to stay anonymous.

Besides filing the complaint, the relator’s attorney will prepare a special memo for the United States Department of Justice explaining the fraud, as well as the evidence the relator has in support of the qui tam case.

The Federal Government’s Investigation

While the qui tam lawsuit is under seal, the Department of Justice will conduct its own investigation of the fraud. The Department of Justice initially has 60 days to complete its investigation. But since this is rarely enough time, they can easily get an extension. In most cases, it takes over 15 months for the DOJ to finish its investigation. Once the investigation is finally over, the Department of Justice will decide whether it will join the relator in the qui tam lawsuit.

The Federal Government’s Decision

The decision for the DOJ to join, or not join, can make or break the qui tam lawsuit. If the Department of Justice decides to join, it will litigate the case along with the relator. But if they choose not to participate, the relator may still proceed with his or her qui tam lawsuit.

If the Department of Justice decides to join the qui tam case, it can drastically increase the chances of success. One reason is due to the fact the DOJ has the resources of the entire federal government behind it. And there is a lot more money in Washington, DC than in any one person’s bank account.

If the Department of Justice decides not to join, that can create a problem because the relator loses out on two things. First, they no longer have the resources of the government to help them in the qui tam lawsuit. Second, it can embolden the defendant and encourage them to fight harder and not settle the case. This is because the Department of Justice will usually only decline to join when they think the case will lose.

One silver lining to the Department of Justice backing out is that if the relator wins the qui tam case, they are much more likely to receive a higher percentage of the money recovered for the federal government.

Qui Tam Litigation Takes Place

Now the case can proceed mostly like any other civil case. The defendant will receive a copy of the complaint. Discovery will take place. Then there is the trial. If the qui tam action settles, it will usually be during the litigation process and before the trial begins.

Interested in Speaking with a False Claims Act Attorney?

Click to find out more about a False Claims settlement by contacting our legal team at Bothwell Law Group online.

How the False Claims Act and Medicaid Interact, and What to Look Out For

Discover how the False Claims Act and Medicaid often go hand in hand.

False Claims Act and MedicaidGiven the size and importance of social welfare programs in the United States, it’s no wonder you will see the False Claims Act and Medicaid close to each other. The bigger the government program, the more money is at stake and the more bureaucracy available to hide the fraud. The purpose of this blog is to explain and discuss the relationship between the False Claims Act and Medicaid.

What Is Medicaid?

Medicaid is an important government program that provides healthcare to those who cannot afford to pay for it themselves. Medicaid is not the same as Medicare. Medicare refers to the government program that provides health insurance services to those who are 65 years of age or older. In simplified terms, Medicaid depends on financial need while Medicare depends on age.

Both federal and state governments handle Medicaid. The program is massive, with costs approaching a trillion dollars each year. With all that money comes the potential for government waste and fraud. That’s where the False Claims Act comes in to fight any fraud that may occur.

What Is the False Claims Act?

The False Claims Act is a federal law that creates legal liability to those who defraud the federal government. It forces those who defraud the government to pay back what they stole, plus additional monetary damages. One of the unique features of the False Claims Act is that it allows individuals (called relators) to bring lawsuits against defrauders to recover money for the federal government. These relators bring the lawsuit on behalf of the government. In return for their efforts, they receive a portion of the money recovered. This portion typically amounts to 15 percent to 25 percent. It can be a little bit higher or lower. It depends on the relator’s level of help provided to the federal government and any involvement in the fraud itself.

How Are the False Claims Act and Medicaid Related?

The False Claims Act affects Medicaid in several ways. First, it allows the federal government to have money it otherwise would not have. The federal government gets this money through a qui tam lawsuit recovery. Or it works by stopping fraud from continuing.

If the federal government recovers money from a healthcare related qui tam lawsuit, it can potentially recover millions of dollars. It can then theoretically use this money to help pay for government operations and programs, including Medicaid. But a more effective way for the federal government to obtain money to help pay for Medicaid is to stop the fraud from continuing.

Let’s say a qui tam action is unsuccessful in recovering any money. There’s a pretty good chance that the fraud no longer takes place. Depending on how much money the government was losing to the fraud, this could amount to millions of dollars each month. And without the qui tam lawsuit or fraud investigation by the Department of Justice (after someone blows the whistle), this fraud could continue undetected for years.

False Claims Act and Medicaid: A Deterrent

Second, the False Claims Act can act as a deterrent. It convinces those who might defraud the government to not to. Perhaps the idea of stealing money from the government sounds great. But consider the potential monetary penalties involved. Adding them on top of returning the original amount stolen often makes the potential fraudster think twice. It’s one thing to pay back what you took. It’s another to have to pay three times the amount you stole. Even worse, there’s an extra $5,000 to $10,000 for each occurrence of fraud. Additionally, they’ll have to consider that because of the qui tam reward, they’ll have to be on the lookout for potential whistleblowers. They might end up revealing the fraud and helping the federal government in its investigation and prosecution.

Third, the False Claims Act can affect Medicaid by adding more paperwork to the healthcare process. Because of the False Claims Act, a healthcare provider that accepts payments through Medicaid has more work to do. They might have special policies and procedures in place to stop its employees from engaging in fraud against the federal government.

Safeguards against Medicaid Fraud

These safeguards could include extra paperwork for doctors and nurses. Or it could mean additional review of billing documentation by outside auditors. All this will cost money, in either extra expenses or lost productivity.

Then there’s the less obvious consequences, such as lower employee morale. The employees may resent that their bosses don’t trust them. Or that they have to do additional work because of a few dishonest workers who commit fraud. This resentment can be especially dangerous because it makes it easier, on a psychological level, for an employee to misbehave. This could include doing something in violation of the False Claims Act. Or it could mean something completely different, such as stealing directly from the employer or even coming into work a few minutes late on purpose.

Find out More about the Relationship Between the False Claims Act and Medicaid

Click to find out more about False Claims Act and Medicaid by contacting our team at Bothwell Law Group online now.