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How to Know if Someone Violated FCA at Work
The False Claims Act (FCA) is a federal law that imposes liability on individuals and companies that defraud the government. This qui tam whistleblower statute enables insiders who blow the whistle on systemic fraud to receive an award of up to 30% of what the government recovers. Many professions may encounter situations that could potentially trigger FCA liability. Here are ten professions that should be on the lookout for potential FCA violations and what they should be specifically on the lookout for:
Healthcare Providers
Healthcare providers should be on the lookout for potential False Claims Act violations related to billing for services not actually rendered, billing for unnecessary services, upcoding (billing for a more expensive service than was actually provided), or double billing (submitting the same claim to multiple payers), as well as anything involving kickbacks. Medicare, Medicaid, and Tricare are the most common government payors in this space. California and Illinois will also allow a whistleblower claim for the systemic defrauding of private insurance with other states considering enacting similar statutes.
Physicians and Nurses
False Claims Act violations can stem from kickbacks on anything related to submitting false claims for services that were not provided or medically necessary, performing medically unnecessary procedures or tests, or billing for services provided by unlicensed or unqualified personnel.
Medical Coders and Billers
False Claims Act violations related to upcoding, unbundling (billing separately for services that should be billed together), or billing for services that are not covered by the patient’s insurance or the government program. Also, Medical coders and billers should be on the lookout for payments to non-employees (contractors, 1099s), based on the outsider providing Medicare or Medicaid patients.
Compliance Officers
False Claims Act violations related to inadequate training, policies, or procedures to prevent fraudulent billing practices, failure to investigate suspected fraudulent activities, or retaliation against whistleblowers who report suspected FCA violations, as well as kickbacks.
Pharmaceutical Industry
Sales representatives need to be vigilant about False Claims Act violations related to offering kickbacks or incentives to healthcare providers to prescribe or recommend their drugs, misrepresenting the safety or efficacy of their drugs, or promoting off-label uses of their drugs that are not approved by the FDA.
Marketing and advertising personnel should be on the lookout for potential FCA violations related to making false or misleading claims about their drugs in advertisements or promotional materials or failing to disclose important safety information or risks associated with their drugs.
Clinical researchers must be on the lookout for potential FCA violations related to falsifying or manipulating data from clinical trials, failing to report adverse events or side effects, or using unapproved or unsafe drugs in clinical trials.
Quality control and manufacturing staff should be on the lookout for processes or defects that are not compliant with CGMP, falsification of approvals either by adulterating the product or the results, releasing quarantined lots without approval, having product bypass approval, failure to report certain material events or manufacturing process changes.
In both the healthcare and pharmaceutical industries, all employees should also be aware of the importance that providing items of value for patients may constitute a kickback and that protecting patient privacy and ensuring the accuracy and completeness of medical records may also have FCA implications if not properly handled.
Defense Contractors
Defense contractors should examine potential False Claims Act violations stemming from submitting false or inflated invoices, failing to comply with contract requirements, or misrepresenting product quality or compliance with regulations. Another facet to BOLO (be on the lookout for) is bribing officials foreign or domestic to obtain a contract which may implicate the Foreign Corrupt Practices Act.
Financial Institutions
Financial institutions should check for potential FCA violations related to mortgage fraud, violations of banking regulations, or submitting false claims for government assistance programs. Financial institutions also have other whistleblower programs that workers can report matters to. For violations of securities law, the SEC whistleblower program, commodities violations, the CFTC whistleblower program, for money laundering violations, the AML whistleblower program and other banking issues covered by Financial Institutions Reform, Recovery, and Enforcement Act (FIRREA).
Government Contractors
Government contractors should check for potential FCA violations related to mischarging or overcharging for goods or services, submitting false or inflated invoices, or violating contract requirements.
Researchers
Employees at research institutions should be on the lookout for potential FCA violations related to falsifying research data or results, submitting false grant applications, or misusing grant funds.
Educational Institution Employees
Education institutional employees should be on the lookout for potential FCA violations related to submitting false or inflated claims for federal student aid programs, misrepresenting enrollment or academic progress, or failing to comply with accreditation requirements.
Construction Contractors
Construction contractors should be on the lookout for potential FCA violations related to submitting false or inflated invoices, misrepresenting project costs, or failing to comply with construction regulations.
Environmental Consultants
Environmental consultants should be on the lookout for potential FCA violations related to submitting false environmental reports or certifications, misrepresenting compliance with environmental regulations, or providing inaccurate environmental assessments.
Transportation Companies
Transportation companies should be on the lookout for potential FCA violations related to overbilling for services or submitting false claims for government transportation programs.
Insurance Employees
Insurance company employees should be on the lookout for potential FCA violations related to submitting false or inflated claims, misrepresenting policy coverage or benefits, or violating insurance regulations.
Overall, it is important for professionals in all industries to be aware of the potential for FCA violations as well as other whistleblower statutes and to ensure that their business practices are transparent and compliant with all applicable regulations. If they’re not the incentives to blow the whistle under various programs has never been greater and whistleblowers stand to receive up to 30% of what the government recovers or more in some circumstances. If you’re in one of the above professions and think this sounds familiar you should have a free, confidential consultation with a whistleblower law firm to learn your rights.