Total Health Care

False Claims Act

Policy

Total Health Care, through its Compliance program and other policies, is committed to the reduction of waste, fraud and abuse in the healthcare system.  As a health plan that receives federal funds, Total Health Care is responsible for establishing and disseminating detailed information regarding Federal and State False Claims Acts and related whistleblower protection laws to all employees, associates, agents and contractors.

Overview

False Claims Act
The False Claim Act is a federal law that makes it a crime for any person or organization to knowingly make a false record or file a false claim regarding any federal health care program, which includes any plan or program that provides health benefits, whether directly, through insurance or otherwise, which is funded directly, in whole or in part, by the United States Government or any state healthcare system. Knowingly includes having actual knowledge that a claim is false or acting with “reckless disregard” as to whether a claim is false.

In addition to the federal law, the state has adopted similar laws under the Michigan Medicaid False Claims Act (MMFCA). The MMFCA is designed to prevent fraud, kickbacks and conspiracies in connection with the Medicaid program.

Examples of false claims include billing for services not provided, billing for the same service more than once or making false statements to obtain payment for services.

Penalties Under the False Claims Act
Violations under the federal False Claims Act can result in significant fines and penalties. Financial penalties to the person or organization includes recovery of three times the amount of the false claim(s), plus an additional penalty of $5,500.00 to $11,000.00 per claim.

Violation of the MMFCA constitutes a felony punishable by imprisonment, or a fine of $50,000 or less, or both, for each violation. A person who receives a benefit, by reason of fraud; makes a fraudulent statement; or knowingly conceals a material fact is liable to the state for a civil penalty equal to the full amount received plus triple damages.

Whistleblower Protection Under the False Claims Act
The federal False Claims Act protects employees who report a violation under the False Claims Act from discrimination, harassment, suspension or termination of employment as a result of reporting possible fraud. Employees who report fraud and consequently suffer discrimination may be awarded (1) two times their back pay plus interest, (2) reinstatement of their position without loss of seniority and (3) compensation for any costs or damages they incurred.

Qui Tam Plaintiff/Relator
An individual (called a qui tam plaintiff or relator) who is an original source of information, can sue for violations of the False Claims Act. Under both the federal False Claims Act and the MMFCA, a qui tam plaintiff can receive between 15-25% of the total amount recovered if the government prosecutes and 25-30% if litigated by the qui tam plaintiff.

Regulations
Public Law 109-171 (Deficit Reduction Act of 2005)

  1. The Federal Civil False Claims Act, Section 1902(a)(68) of the Social Security Act
  2. The Federal Civil False Claims Act, Section 3279 through 3733 of title 31 of the United States Code.
  3. The Michigan Medicaid False Claims Act, Public Act 72 of 1977