The False Claims Act has been around for over 150 years. It makes it against the law to knowingly submit a false claim to the federal government. It provides for civil penalties as well as criminal ones. The government is entitled to three times the amount it actually lost as a result of the false claims.
The statute also has a whistleblower provision which allows someone with knowledge of a false claim to file suit to recover the improper payments on behalf of the federal government. The government has the option of taking over the litigation. If the federal government does and makes a financial recovery, the whistleblower gets a cut. If the government does not wish to take over the case and the whistleblower proceeds and wins, he or she gets a larger share of the recovery than they would have if the federal government had taken it.
A few weeks ago three cardiologists from Mesa, Arizona agreed to pay $4.75 million in a civil settlement to resolve allegations that they submitted multiple false claims over a five year period. The claims were submitted to Medicare, Medicaid, TRICARE, and the Veterans Administration. According to the allegations, the cardiologists submitted bills for performing ablations on leg veins. The procedure is performed to fix problems with venous insufficiency, in which the veins no longer do their job of returning venous blood to the heart, or to fix varicose veins. The procedure involves the use of a heat source or glue to close off the offending veins.
In order for a vein ablation to be medically necessary, the vein must be of a certain minimum size. If it is below the minimum size, whatever problem it may be causing is medically insignificant and is deemed not worth treating with ablation.
The federal government alleged the Mesa cardiologists were not only performing ablations on veins too small to justify the procedure, but were falsifying the patient records in a number of respects to make it appear the veins qualified for the procedure. According to the government, this altering of the medical records showed the doctors knew what they were doing was wrong and satisfied the requirement that the false claim be “knowingly” submitted.
Although the doctors and their cardiology practice denied the allegations, they agreed to pay the $4.5 million and not to seek reimbursement of these claims in the future.
Billions of dollars flow through these federal programs each year. There are many people trying to improperly divert a portion of this flow to themselves. Unfortunately, only a few get caught. If you know of fraudulent claims or conduct involving federal health care programs, or any federal program, for that matter, consider using this statute to help the government and yourself.
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