The feds are aggressive when it comes to pursuing allegations of healthcare fraud. One of their favorite legal tools to use when building these cases is the False Claims Act (FCA). This law basically states that the feds can go after any business that falsely bills a government body, like the Centers for Medicare and Medicaid Services (CMS).
How serious are these allegations?
An allegation of an FCA violation can come with serious consequences. The business that faces the allegations can face steep financial penalties and may lose the ability to continue to bill Medicaid. In some cases, the government could even use the law to go after individuals it believes have wronged the system.
The feds are motivated by the success of these cases. During the fiscal year ending in Sept 30, 2021, the feds got over $5 billion in settlements and judgements relying on FCA cases alone.
What types of organizations are the subject of FCA investigations?
Basically any business that bills the government. The feds will go after massive healthcare organizations and small businesses alike. In a recent example out of a relatively small town in Wisconsin, the feds went after a pharmacy for more than $2 million in alleged false claims violations. The feds claim the pharmacy unnecessarily switched patients from a lower cost medication to a more expensive version without medical need or a valid prescription.
The case provides three important lessons for pharmacies throughout the country:
1) Size doesn’t matter. This was a relatively small pharmacy that still got intense government scrutiny for its practices.
2) Complaints often come from within. The case was triggered by a whistleblower from the pharmacy.
3) You can move on. The pharmacy in this example agreed to settle the claim by paying the government $2 million and put training measures in place to avoid similar problems in the future.
It is important to discuss settlement and litigation options with a legal professional. An attorney can review the options and help to better ensure you understand the risks and benefits of each and may be able to negotiate a better resolution on your behalf.
Attorney John Rivas is responsible for this communication