Healthcare organizations, workers, and physicians should be aware of qui tam lawsuits and their implications. These lawsuits are becoming more prevalent in the healthcare industry and can have negative impacts for workers and employers. Qui tam lawsuits are filed by individuals who may also be called whistleblowers.
Under the False Claims Act (FCA), qui tam lawsuits can give those with proof of fraud against federal programs and contracts the ability to sue the accused. These are done in the interest of the U.S. Government, and in some cases, the government will join in on the lawsuit. If not, plaintiffs can pursue these lawsuits on their own. Plaintiffs can be awarded up to 30 percent of the payout, which explains why there are so many. The monies are a reward that the whistleblower receives for exposing the fraud and getting the government involved.
Fines and Penalties
The FCA specifies that organizations can be liable for three times the amount of a false claim that they filed for. This is in addition to civil penalties; the range has been doubled and may cap off at over $20,000 per claim. In fiscal year 2016, the Justice Department was able to recover more than $4.7 billion dollars in fraudulent cases; over 50 percent were from the healthcare industry.
False Claims Act Violations
Knowingly providing the federal government with fraudulent claims, using false records, and conspiring with others to receive payment for false claims constitutes as illegal behavior. Over the past decade, the Patient Protection and Affordable Care Act increased the scope of what false claims entail. Violating Medicare and Medicaid regulations, failing to report overpayment within a specified time frame, and quality of care can all fall under the umbrella of this Act.
Preventing Qui Tam Lawsuits
Qui tam lawsuits can be costly and are based on violations that were made without intention. Being proactive and offering the best patient care should be the main goal. A fundamental way to avoid these lawsuits is to follow Medicare and Medicaid guidelines for patient care. Policies and procedures should also cover processes for record-keeping, billing, and filing claims. Employees should undergo FCA compliance training as well.
Many whistleblowers in qui tam lawsuits are current or former employees. This can happen when the employee becomes angry about a work situation that they were not able to resolve. Therefore, it is important to maintain open communication with every member at the office, and to address any questions or complaints right away.
Monitoring FCA compliance should also be prioritized. Designating a compliance officer or department for the company can be very beneficial. Holding regular meetings, receiving employee feedback, and continuing education on the topic can help medical organizations avoid qui tam lawsuits.