Federal False Claims Act, KY Fraud and Abuse Laws, Indiana Fraud and Abuse Laws
Federal False Claims Act
The Federal False Claims Act (FCA) is a Federal law that prohibits, among other things, the knowing filing of a false or fraudulent claim for payment, the knowing use of a false record or statement to obtain payment on a false or fraudulent claim paid by the United States, or the conspiracy to defraud the United States by getting a false or fraudulent claim allowed or paid. The FCA allows any person who discovers that a government contractor is defrauding the Federal government to report it, and then to sue the wrongdoer on behalf of the U.S. government. In general, the FCA covers fraud involving any federally-funded contract or program, with the exception of tax fraud.
In FCA lawsuits, known as qui tam suits, the Federal government has the right to join the private citizen’s lawsuit. If the government is then able to collect from the fraudulent contractor, the law allows the whistleblower to share in the proceeds. If the government declines, the individual may proceed on his or her own. The FCA also contains an anti-retaliation provision which protects those who make FCA-protected disclosures or file a qui tam suit. Knowingly violating Medicare laws and the Medicare Fraud and Abuse Statute also violates the FCA. Hospitals, doctors, home healthcare agencies, and laboratories that seek and receive reimbursement for Medicare and Medicaid funds are subject to the False Claims Act. Some of the ways a healthcare provider can violate the FCA include:
- Knowingly billing for services not rendered.
- Misrepresenting the type of goods or services rendered.
- Misrepresenting the nature of the patient’s illness.
- Failing to provide correct data on annual hospital or nursing home cost reports to the government, if the errors were knowing or intentional or
- Providing substandard care.
Any persons or entities with evidence of fraud against Federal programs or contracts may file a qui tam lawsuit, as long as the government or another private party has not already filed a lawsuit based on the same evidence.
Those who violate the False Claims Act can be required to pay three times the dollar amount that the government was defrauded (known as “treble damages”) and civil penalties of $5,500 to $11,000 for each false claim. A qui tam suit is a civil action, not a criminal action. For that reason, imprisonment is not a potential sanction in a qui tam case. However, filing a qui tam action may trigger a criminal investigation and prosecution by the government which could lead to criminal fines or jail time for the wrongdoer(s).
Any associate who discovers wrongdoing that violates the FCA is protected from being discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of employment by his or her employer because of lawful acts done by the employee in furtherance of an FCA action. The anti-retaliation provision protects employees who engage in lawful acts in furtherance of a FCA action. This includes investigation for, initiation of, testimony for, assistance in, or harassed because of an FCA action filed or to be filed. The protection against retaliation extends to whistleblowers whose allegations could legitimately support an FCA case even if the case is never filed.
Those who violate the FCA are liable for three times the dollar amount that the government is defrauded and civil penalties of $5,500 to $11,000 for each false claim. A qui tam plaintiff can receive between 15 and 30% of the total recovery from the defendant, whether through a favorable judgment or settlement.
Under the anti-retaliation section of the FCA, any employee who is discharged, demoted, harassed, or otherwise discriminated against because of lawful acts by the employee in furtherance of an action under the Act is entitled to all relief necessary to make the employee whole, which may include reinstatement, double back pay, and compensation for any special damages, including litigation costs and reasonable attorneys’ fees.
Kentucky Fraud and Abuse Laws
Kentucky also has enacted laws to protect the financial integrity of the Kentucky Medical Assistance Program through the investigation and prosecution of healthcare providers who fraudulently bill or abuse the Medicaid system to obtain benefits or payment for services.
The Kentucky Fraud and Abuse Laws define “fraud” as “an intentional deception or misrepresentation made by a recipient or a provider with the knowledge that the deception could result in some unauthorized benefit to the recipient or provider or to some other person. It includes any act that constitutes fraud under applicable federal or state law.” Examples of fraud under the Kentucky Fraud and Abuse Laws would include those activities listed above as examples of violations of the FCA.
Those found to have violated the Kentucky Fraud and Abuse laws shall be liable for (a) restitution in the amount of the excess payments, plus interest; (b) a civil payment in an amount up to three times the amount of excess payments; (c) a civil payment of five hundred dollars ($500) for each false or fraudulent claim submitted for providing treatment, services, or goods; and (d) payment of legal fees and costs of investigation and enforcement of civil payments.
In addition, those found to have violated the Kentucky Fraud and Abuse Laws will be removed as a participating provider in the Medical Assistance Program for two months to six months for a first offense, for six months to one year for a second offense, and for one year to five years for a third offense.
Any person who has reasonable cause to believe that a violation of the Kentucky Medicaid Fraud and Abuse laws is being committed should report the violation to the Medicaid Fraud Control Unit or the Medicaid Fraud and Abuse hotline. The identity of the person making such a report will be kept confidential by the party receiving the report.
Employers are not permitted, without just cause, to discharge or in any manner retaliate against any employee who in good faith makes such a report, or who participates in any proceeding with regard to any such report or investigation. An employee injured by any act in violation of the prohibition against employer retaliation may pursue a civil cause of action to enjoin further violations, and to recover the actual damages sustained, together with the costs of the lawsuit, including reasonable attorneys’ fees.
Indiana Fraud and Abuse Laws
Indiana’s state version of the federal False Claims Act makes it unlawful for any person to knowingly or intentionally: (a) present a false claim to the State for payment or approval; (b) make or use a false record or statement to obtain payment or approval of a false claim from the State; (c) with the intent to defraud the State, deliver less money or property to the State than the amount recorded on the certificate or receipt the person receives from the State; (d) make or use a false record or statement to avoid an obligation to pay or transmit property to the State; (e) conspire with another person to perform an act described above; or (f) cause or induce another person to perform an act described above.
A violator will be liable to the State for a civil penalty of at least $5,000 and for up to three times the amount of damages sustained by the State. The violator shall also be liable to the State for cost of a civil action brought to recover a penalty or damages.
The Indiana Attorney General and the Inspector General have concurrent jurisdiction to investigate suspected violations of the Indiana False Claims Act and the Attorney General may bring civil action against a person that has violated the Indiana False Claims Act. An individual may also bring a private civil action on behalf of the individual and the State. In the event the qui tam action is successful, the individual bringing the civil action may be awarded a percentage of the funds recovered.
The Indiana False Claims Act contains an employee protection provision that provides that any employee who is discharged, demoted, suspended, threatened, harassed, or otherwise discriminated against in the terms and conditions of employment by his or her employer because the employee initiated testified, assisted, or participated in an Indiana False Claims Act investigation, action or hearing, shall be entitled to relief necessary to make the employee whole. Such relief includes, but is not limited to, the following: reinstatement with the same seniority status that the employee would have had but for the discrimination, two times the amount of back pay, interest on the back pay, and compensation for any special damages sustained as a result of the discrimination, including punitive damages, litigation costs and reasonable attorneys’ fees.
Indiana’s Medicaid antifraud laws state that a person may not knowingly or intentionally: (a) make, utter, present or cause to be presented to the Medicaid program, a Medicaid claim that contains materially false or misleading information concerning the claim; (b) obtain payment from the Medicaid program by means of a false or misleading oral or written statement or other fraudulent means; (c) acquire a provider number under the Medicaid program except as authorized by law; (d) alters with the intent to defraud or falsify documents or records of a provider that are required to be kept under the Medicaid program; or (e) conceal information for the purpose of applying for or receiving unauthorized payments from the Medicaid program. A person who violates the above prohibitions, may be guilty of the following: (a) a Class A misdemeanor; (b) a Level 6 felony if the fair market value of the offense is at least $750 and less than $50,00; and (c) a Level 5 felony if the fair market value of the offense is at least $50,000.
Rights & Remedies under the ARRA of 2009
The American Recovery and Reinvestment Act of 2009 (ARRA) provides funding for research and other healthcare needs. In order to accept ARRA funding, employers must have in place policies prohibiting retaliation against employees/associates who make good faith reports of misconduct. St. Elizabeth Healthcare already has such a policy, #300.045, “Associate, Provider or Contractor/Vendor Discipline for Corporate Compliance Program-Related Infractions,” and will provide appropriate support to reporting associates to protect against retaliation and respond to concerns of retaliation or unfair treatment linked to the associate’s reporting.
The ARRA expressly states that:
Receivers of stimulus funds may not discharge, demote or otherwise discriminate against an employee as reprisal for disclosing information that the employee reasonably believes is evidence of:
- Gross mismanagement of an agency contract or grant relating to covered funds;
- A gross waste of covered funds;
- A substantial and specific danger to public health or safety related to the implementation or use of covered funds;
- An abuse of authority related to the implementation or use of covered funds; or
- A violation of law, rule, or regulation related to an agency contract or grant awarded or issued relating to covered funds.
Under ARRA, an employee may make a disclosure of the information described above to one or more of the following: the Recovery Accountability and Transparency (RAAT) Board; an Inspector General of a federal agency; the Comptroller General; a member of Congress; a State or Federal regulatory or law enforcement agency; a person with supervisory authority over the employee or such other person working for the employer who has the authority to investigate, discover or terminate misconduct; a court or grand jury; or the head of a Federal agency or their representatives.
St. Elizabeth Healthcare has a confidential reporting hotline that may be used for this purpose (toll-free 1 (877) 815-2414), where anonymous reports may be made. In addition, associates also have the option of reporting concerns directly to the Office of Inspector General for the United States Department of Health and Human Services through the OIG Hotline. The choice of which reporting option(s) to use rests with the individual making the report.
A full description of rights and remedies provided under the ARRA is available from the US Government Printing Office: Division A, Title XV, section 1553, Protecting State and Local Government and Contractor Whistleblowers. Additional information regarding whistleblower protection related to ARRA funds may be found at www.oig.dol.gov.