Dealing with Fraud
Health care fraud is all about the money. A small group of offenders may believe the rule simply does not apply to them; a few may be motivated by the thrill of outsmarting a complex regulatory system; and occasionally someone may view fraud as a political act of protest against unwarranted governmental intrusion into health care. However, in the vast majority of cases health care fraud occurs simply because, as Professor Pamela Buey long-ago noted, "that's where the money is.” However, the relationship between health care fraud and the U.S. health care system is far more complex than might first appear. Would-be thieves and hucksters or "fraudsters," to use the common lingo, are not the only ones who respond to the financial incentives and disincentives in the system. Due to the unique nature of the laws used to pursue health care fraud, both public and private prosecutors also follow the money in choosing their targets and both may share in the spoils of a successful prosecution (Krause, 2010).
Healthcare Qui Tam Affects on Health Care Organizations
Federal regulators have aggressively prosecuted health care fraud since the early 1990s, leading to billions of dollars in financial recoveries. Nearly all major cases today are qui tam actions, involving whistleblowers with inside knowledge of the allegedly illegal schemes (Kesselheaim & Studdert, 2008). According to Ruhnka and Gac (2000), “the FCA rewards .such whistle-blowers with a share of any resulting recoveries as a bounty and protects them from discharge for filing false claims lawsuits against their employers” (p. 283). It also requires defendants to pay the costs and attorney’s fees of successful claimants (Ruhnka & Gac, 2000).
The centerpiece of antifraud regulation is the federal False Claims Act (FCA). The FCA dates from the Civil War era and prohibits the “knowing” submission of false claims or statements to the government, which can include reckless ignorance or...