With the passage and newly implemented Patient Protection and Affordable Care Act (“ACA”), sometimes referred to as “Obamacare”, there are a number of new mechanisms that provide incentives and remedies to those in a position to recognize and report fraud against the government. Such health care fraud often comes in the form of Medicare reimbursements or Medicaid reimbursements that are intentionally “off” in some way, allowing the entity seeking reimbursement to recover a greater amount to which it is entitled than it should under the applicable laws. Other examples are below.

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Role of Whistleblowers

Fraud against the government can be pursued by private individuals that have, among other things, intimate knowledge of the fraud and are the first to file the action. Such individuals are referred to as “whistleblowers” and the actions themselves are often called False Claims Act cases or Qui Tam actions. Simply put, there are many violations of the fraud and abuse provisions in the ACA that trigger a cause of action under the False Claims Act (“FCA”).

Fraud Against the Government

Examples of such violations include:

• Improper billing, billing for services not rendered and other fraudulent billing practices
• Off-label marketing of drugs and devices by pharmaceutical companies
• Up-coding schemes and unbundling
• Kickbacks, self-referrals and other forms of illegal remuneration
• Performing operations that are not medically necessary
• Failing to provide quality care to patients/failing to meet the expected standard of care
• Submitting false cost reports
• Grant or research fraud
• Lab fraud
• Medical device fraud
• Failure to maintain adequate compliance programs
• False reporting and certification

Front Lines in Fraud Reporting

Those in a position to recognize and potentially report health care fraud include employees, independent contractors, compliance officers, accountants, bookkeepers, secretaries, physicians, non-physician practitioners, nurses, LPN’s and anyone else who has knowledge of the details amounting to medical industry fraud against the government.