Anyone who receives notification of an investigation or allegations of healthcare fraud may wonder where the accusations came from. This is a question that can have a few different roots. Two examples include the following.
Option #1: A whistleblower
One of the more common options is government notification of a potential Anti-Kickback Statute (AKS) violation from a whistleblower. A former employee or co-worker may file a claim to bring attention to what they see as potential healthcare fraud. This individual may have a genuine concern for potential wrongdoing or may act out in spite. Whatever the cause for the claim, the individual is likely motivated by the potential for a payout. If the claim is successful, the whistleblower stands to get a percentage of any of the winnings that result from the case.
The individual is not the only one that stands to gain from these types of cases. Legal counsel can also be motivated to encourage these claims as they can also have their fees covered by the winnings. It is generally wise to seek your own legal counsel to navigate the allegations since you are likely to have a well-represented adversary.
Option #2: Red flag from an audit
The accusations can also be part of an Office of the Inspector General (OIG) audit. The feds regularly analyze data to flag outliers. These outliers may then be subject to an audit. Depending on the results of the audit, the government may choose to pursue charges and recoup what it believes are ill-gotten gains.
Whether the result of an audit or allegations of wrongdoing from a whistleblower, those who face claims of healthcare fraud are wise to take the matter seriously. If convicted, the accused can face steep financial penalties as well as potential imprisonment.
Attorney John Rivas is responsible for this communication.