Health Care Fraud
Health care fraud may encompass many types of practices such as illegal kickbacks (receiving reimbursement for referrals), billing for services not rendered, billing for unnecessary equipment, and billing for services performed by a lesser qualified person. The health care providers who commit these fraud schemes include hospitals, home health care providers, ambulance services, doctors, chiropractors, laboratories, pharmacies, hospices and nursing homes. A private citizen can file a lawsuit in the name of the United States Government against companies that defraud Medicare and other federal health care programs. Medicare is a health program for the elderly financed through a federally-administered trust fund.
Violators
may be prosecuted under the False Claims Act (“FCA”).
This federal statute was originally passed by Congress in 1863 at the
urging of President Abraham Lincoln. He was concerned about the numerous
fraudulent suppliers who sold the Union Army faulty war supplies during
the Civil War, including broken rifles, rancid food, and useless ammunition.
The 1863 FCA provided both criminal and civil penalties for those defrauding
the government and, therefore, was a way to combat the rampant fraud
against the government. The FCA also contained a qui
tam provision
that permitted an individual initiating the suit, the whistleblower,
to collect a percentage of the damages. The term qui
tam refers to a lengthier Latin phrase which
translates into English as "one who sues on behalf of the King, as
well as for himself." Many
states have passed laws similar to the federal FCA allowing the state
to recover damages for fraud against the state Medicaid program. Medicaid
is another health program for low-income individuals administered separately
by each state.
The whistleblower can only bring a claim in a case in which the government is unaware of the fraud and the information precipitating the action. It is also important for the whistleblower to be the initial source of information regarding the fraud in order to be entitled to a percentage of the damages.
Fraudulent billing and billing for medically unnecessary services is prevalent throughout the United States. Health care fraud is expected to increase as people live longer. This increase will produce a greater demand for Medicare benefits. As a result, the utilization of long and short-term care facilities such as skilled nursing, assisted living, and hospice services most likely will expand substantially in the future.
Links:
» Association of Certified Fraud Examiners
» Taxpayers Against Fraud Education
Fund
» National Health Care Anti-Fraud Association
» Government
Accountability Project
» Project
on Government Oversight