The ICS has advised its members early and often: federal and state regulators have for some time prioritized the prevention and prosecution of health insurance fraud. The HHS Office of the Inspector General, reporting on the Health Care Fraud and Abuse Control program for 2017-2019, cited a greater than 400% rate of return on investment ($4.2 returned for every $1.00 expended). To bolster this initiative, laws have created incentives for private persons having knowledge of fraud – often referred to as “whistleblowers” – to assist the government by initiating litigation and sharing in money damages in successful cases.
As most doctors know, under federal law, any person or entity may be prosecuted for soliciting or receiving remuneration or “kickbacks” in exchange for referring patients for services under any federal health care program. And, under the federal False Claims Act, private individuals may assist the government in prosecuting these cases by bringing a lawsuit on behalf of the United States, where the private person has information that the named defendant has knowingly submitted false or fraudulent claims to the United States. The “whistleblower” (legally termed the “relator”) need not have been personally harmed by the defendant’s conduct in order to bring suit.
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