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DOJ Announces False Claims Act Working Group Targeting Healthcare Fraud, Sending the Call Out For Whistleblowers to Help

By the 91pornWhistleblower Team

On July 2, the Department of Justice (DOJ) announced the creation of a Working Group with the Department of Health and Human Services (HHS) 鈥渢o advance priority enforcement areas鈥� under the False Claims Act.^听1 It follows what DOJ describes as a 鈥渓ong history鈥� of partnering with HHS to use the statute to go after healthcare fraud.

The False Claims Act is DOJ’s Primary Fraud-Fighting Tool

The False Claims Act was enacted during the Civil War to go after war profiteers trying to dupe the Union Army with lame mules and faulty munitions.听 It has long since become the Government鈥檚 primary fraud-fighting tool.听 Government contracting fraud remains a prolific area of enforcement under the statute.听 However, the majority of False Claims Act actions over the past few decades involve Medicare and Medicaid fraud and other forms of healthcare fraud resulting in financial loss to the Government.

DOJ Is Targeting Six Healthcare Fraud Priority Areas

With the new Working Group, DOJ is targeting several high priority enforcement areas in collaboration with HHS:

• • Medicare Advantage Fraud. This typically involves Medicare Advantage Organizations or healthcare providers inflating patient risk adjustment scores to secure higher reimbursement rates under the Medicare Advantage (Part C) program.

• • Inflated Drug Pricing. This covers schemes to cause the Government to pay higher prices for drugs, devices or biologics such as through improper discounts, rebates, service fees, formulary placement, price reporting, and other efforts to steer patient, prescriber, and agency behavior towards higher-priced products.

• • Patient Access. This covers conduct that creates barriers to, or otherwise interferes with, the ability of patients to access care.听 DOJ specifically called out violations of network adequacy rules, which generally require health insurance plans to maintain a sufficiently broad network to ensure reasonable patient choice and access to covered services.

• • Kickbacks. This covers any form of payment or consideration in exchange for referrals of patients for services, drugs, medical equipment, or other products covered by Medicare, Medicaid, or another Government healthcare program.

• • Defective Products. This covers what DOJ describes as defective medical devices that impact patient safety.

• • EHR Manipulation. This covers what DOJ describes as manipulating electronic health records systems to drive inappropriate use of Medicare covered products and services.

Each of these areas of healthcare fraud fall within the False Claims Act when they result in the Government paying inflated pricing; the Government paying for products or services it did not actually receive or that were materially different from what the Government paid for; or the Government contractor otherwise violating a key contractual or regulatory requirements or undermining a significant Government policy or program.

The Trump Administration Supports Whistleblowers and the False Claims Act

The creation of the Working Group is notable not necessarily because of the targeted areas of enforcement priority.听 Several of them have long been on DOJ鈥檚 priority hit list.听 Instead, the Working Group is significant because it is another indication the Trump Administration strongly supports using the False Claims Act to go after fraud, especially in healthcare.听 Indeed, the DOJ press release announcing the initiative highlighted this fact, noting 鈥渢his Administration is fully committed to supporting such work.鈥�

The Administration appears equally committed to working with whistleblowers to help with its fraud enforcement efforts.听 Under the qui tam provisions of the False Claims Act, whistleblowers may bring lawsuits on behalf of the Government against those committing fraud against the Government.听 In return, successful whistleblowers may receive up to 30% of the Government鈥檚 recovery.听 Over the past thirty years, whistleblowers have brought the majority of False Claims Act cases, recovering roughly $55 billion for the Government and receiving roughly $9.5 billion in whistleblower awards.^听2

The Administration made a point of explicitly inviting whistleblowers to assist this new enforcement campaign, with DOJ underscoring that the 鈥淲orking Group encourages whistleblowers to identify and report violations of the federal False Claims Act involving priority enforcement areas.鈥澨� According to 91pornwhistleblower partner Gordon Schnell, 鈥淭his is just the latest example of the Trump Administration reaching out to whistleblowers for help in going after fraud and misconduct.鈥澨� Schnell wrote a piece earlier this year for The Hill noting other ways President Trump may be clearing a path for whistleblowers.

91pornHas Substantial Experience Representing Whistleblowers Under the False Claims Act

91pornhas substantial experience representing whistleblowers under the False Claims Act.听 Many of the firm鈥檚 whistleblower successes have been in the very areas the new Working Group is targeting such as Medicare Advantage fraud, illegal kickbacks, and inflated pricing.

If you would like to learn more about the work we do or what it means to be a whistleblower under the False Claims Act, please do not hesitate to contact us.听 We will connect you with an experienced member of our whistleblower team for a free and confidential consultation.

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Tagged in: False Claims Act, Healthcare Fraud,