While the United States federal government is a powerful force, it is not always able to detect every fraudulent behavior. Because of this, private citizens are encouraged to voice concerns.
The False Claims Act (FCA), 31 U.S.C. §§ 3729 – 3733, is a federal statute that grants private citizens the right to file qui tam suits against those committing fraudulent behavior. When agencies commit fraud, it impacts the relevant industry at large and disservices many individuals.
Relators who feel they have substantial evidence should file a suit to ensure proper repercussions are followed and justice is served.
The False Claims Act statute of limitations states that an FCA action may be brought:
Because the government understands the uncertainties in creating a substantial False Claims Act case, it has set these time requirements to allow citizens to ensure their claims are lawful.
However, it is important to ensure timeliness when filing cases not only to follow the False Claims Act statute of limitations but also to satisfy the first-to-file requirement.
False claims acts can occur in many different industries. In the healthcare industry, False Claims Acts can be filed by a variety of relators for various reasons including:
Read further on high-profile False Claims Act healthcare cases to understand the importance of filing claims.
One of the largest for-profit hospital chains, HCA Inc. was charged $16.5 million to settle a False Claims Act suit in 2012, though it was not their only time convicted.
The chain allegedly provided financial benefits to Diagnostic Associates of Chattanooga in exchange for referring patients to HCA-owned facilities. HCA’s actions violated the Stark Statute and federal law which restricts financial relationships between hospitals and physicians who may refer patients to them.
Financial bribes or kickbacks, impact the healthcare system at large because they may tamper with the patient’s best interest when specific practices, products, or treatments are heavily advised by their provider as opposed to other options.
While this case ended in a civil settlement, the whistleblower who presented the case received a percentage, and the facility was penalized to pay whistleblower legal fees, proving the consequences of engaging in kickbacks.
In September 2021, the Sutter Health case was the largest FCA settlement ever paid by a health care provider for alleged Medicare Advantage fraud.
The suit was filed by a former employee, alleging that Sutter Health knowingly submitted diagnosis codes to its contracted MA Plans that were inconsistent with the patients’ medical records, making them appear sicker, in order to benefit from its reimbursement plan.
Medicare Advantage programs are paid based upon a capitated (per-enrollee) monthly amount which is then risk-adjusted for patient health, causing increased MA reimbursement for the treatment of sicker patients.
Cases like these “diverts funds from this vital health care program, which is a disservice to patients needing care,” according to the Office of Inspector General of the U.S. Department of Health and Human Services.
In 2021, a Texas hospice CEO, Henry Mcinnis, was charged after allegedly lying to patients with long-term incurable diseases about their life expectancy to increase enrollment in their hospice center for profit gain. Employees were forced into fraudulent behavior by consequences including termination of employment.
Hospices are paid per-diem, meaning the dollar amount is set in regard to the number of patients enrolled as opposed to the services performed, which financially rewards a hospice that has fewer services and enrolls more patients. Because of this, hospice facilities like Merida Group may feel tempted to commit fraud by the anticipated increase in profit.
The Merida Group’s employees submitted claims against Henry Mcinnis and other executives for $150 million dollars which were thought to be pocketed to fund their lavish lifestyles. After the completion of the investigation and trial, McInnis was convicted on six counts of health care fraud and one count each of conspiracy to commit healthcare fraud, obstruction of justice, and conspiracy to commit money laundering. His co-conspirators Rodney Mesquias and Francisco Pena were also found guilty.
Hospice fraud accusation can be a business-altering experience especially given the vulnerability and desperation of its clients. These claims not only impact those involved financially but often emotionally as well.
The cases above serve as a primal example of the stakes of healthcare fraud. When an individual is suffering physically and emotionally from a medical condition of any kind, they are in a vulnerable state and may be willing to agree to any relief suggested.
Healthcare providers and medical corporations have a high influence on patients which is not to be taken advantage of. Fraudulent behaviors can be prevented and deterred by False Claims Act lawsuits which result in individual justice, and overall relief for the system as a whole.
Fenton Law Group has successfully defended healthcare providers against False Claims Act allegations, representing both defendants and plaintiffs. The skillful and dedicated team of false claims attorneys will work with you to create a personalized approach to your case.
If you have witnessed another direct entity take part in fraudulent behavior, message us or call us for a consultation on your case.