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Fraud & False Claims

Today’s healthcare environment involves increasing governmental monitoring of fraud, waste, and abuse of Medicare and Medicaid healthcare funds through investigations and payment recovery initiatives.

Fraud is defined as the intentional false representation or concealment of a material fact for the purpose of inducing another to act upon it to his or her injury. Each member of the management team will be familiar with the types of improprieties that might occur within his or her area of responsibility, and be alert for any indication of irregularity.

The False Claims Act (31 United States Code Sections 3729-33) is a federal anti-fraud law that originated during the Civil War. Violations of this Act can include knowingly submitting a false claim to the government for payment (in our case, Medicare/Medicaid reimbursements); making or using a false record or statement to obtain payment for a false claim; conspiring to make a false claim or to get paid; or, making or using a false record to avoid payments to the U.S. Government.

Whistleblowers may file a lawsuit on behalf of the government and are protected from termination, demotion or other negative consequences as a result of reporting fraud.

Penalties for violating the False Claims Act are significant and can total as much as three times the claim amount, plus fines ranging from $11,665 to $23,331 per claim. Exclusion from future participation in federal government healthcare programs (i.e. Medicare/Medicaid) may also result and, in some cases, individuals may serve jail time. Alabama also has a Medicaid anti-fraud statute that makes it a felony to submit false claims or statements to the Alabama Medicaid Agency.

External investigations targeting fraud, waste and abuse may be announced in the form of paper or electronic communications. If you receive an investigation announcement from a government agency, report this to the Corporate Compliance Officer (CCO) at 205-638-7134 immediately. These are time-sensitive investigations and responses must be filed by the designated deadline. Delay in reporting such announcements to the CCO may jeopardize Children’s position in the investigation.

For more information on fraud and the False Claims Act, please refer to these policies in Lucidoc:

  • False Claims Act
  • Fraud
  • Responding to External Investigations