Copyright© 2011 WeComply, Inc. All rights reserved. 9/6/2015 Whistleblowing

Copyright© 2011 WeComply, Inc. All rights reserved.

04/19/23

Whistleblowing


04/19/23

Whistleblowing

Copyright© 2011 WeComply, Inc. All rights reserved. 3

Healthcare Fraud: The Big Picture

U.S. government spends $500 billion annually on healthcare

Healthcare fraud drains $70 billion annually from federal healthcare funds

Best defense against healthcare fraud: Vigilant employees who "blow the whistle" on fraud or other misconduct

More than half of U.S. government fraud recoveries involve healthcare

Law provides rewards and protections for whistleblowers


In the news…

Anti-Fraud Spending No-Brainer

With fraud draining $70 billion annually from federal healthcare funds, federal authorities are ramping up their efforts to curb Medicare fraud. In three major multi-state sweeps over the course of two months, authorities made 140 arrests and recovered more than $370 million. A recent study concluded that for every dollar spent to investigate and prosecute healthcare fraud in civil cases, the federal government receives fifteen dollars in return.

Funds Spent on Prosecution Yield Big Returns


The False Claims Act

False Claims Act (FCA) provides whistleblowing protections and rewards

•Enacted during Civil War to punish abuses by government contractors

•Amendments provide citizens with incentives to expose fraud

FCA is the best tool to recover U.S. government funds diverted through fraud

•Companies that submit false claims are liable for three times the government's damages, plus civil penalties

•FCA also provides administrative remedies

FCA prohibits many different types of fraud


The False Claims Act (cont’d)

False Claims Act (FCA) provides whistleblowing protections and rewards

•Enacted during Civil War to punish abuses by government contractors

•Amendments provide citizens with incentives to expose fraud

FCA is the best tool to recover U.S. government funds diverted through fraud

•Companies that submit false claims are liable for three times the government's damages, plus civil penalties

•FCA also provides administrative remedies

FCA prohibits many different types of fraud


Types of Healthcare Fraud

Healthcare fraud can arise through —

•Providing goods and services

•Providing gifts, business courtesies, meals, discounts and rebates

•Giving educational grants, funding for research or studies, or charitable contributions

Common forms of healthcare fraud:

•Charging exorbitant prices

•Billing for products or services not provided

•Billing for medically unnecessary services

•Paying or receiving kickbacks


Alert!

Forms of Healthcare Fraud

One of the most common types of healthcare fraud is billing for goods or services not provided. For example, healthcare fraud may occur when —

• A physician's office overstates the duration of an office visit;

• A medical school claims to provide coverage by a physician, when the coverage was actually provided by a resident;

• A laboratory claims to have performed tests or X-rays that it did not perform;

• A pharmacy dispenses less than the prescribed amount of a drug but charges for the full prescription;

• A medical transportation provider overstates mileage for trips; and

• A fake provider organization systematically obtains personal healthcare information from individuals, then files false claims for services supposedly provided to those persons.


Qui Tam Suits

Under FCA, employee with knowledge of fraudulent misconduct can bring qui tam lawsuit

•Lawsuit is on behalf of government

•If lawsuit results in recovery by the government, employee is entitled to up to 30%

FCA provides financial incentive for employees to become whistleblowers

Person who files qui tam suit is called the relator


Qui Tam Suits (cont’d)

Under FCA, employee with knowledge of fraudulent misconduct can bring qui tam lawsuit

•Lawsuit is on behalf of government

•If lawsuit results in recovery by the government, employee is entitled to up to 30%

FCA provides financial incentive for employees to become whistleblowers

Person who files qui tam suit is called the relator


Special Note…


Evaluating a Possible Qui Tam Suit

To bring a qui tam suit under the FCA —

•Whistleblower must have actual knowledge of the fraud

•Evidence of fraud must be specific

•Fraud must involve federal money

Factors that preclude a qui tam suit:

•Fraud involves tax fraud

•Evidence comes from a public source

•A state is alleged to have defrauded the federal government


Whistleblower Protection

Whistleblower laws protect those who —

•Complain in good faith of illegal activity

•Lawfully attempt to stop illegal activity

•Participate in resulting investigation of illegal activity

We encourage employees to disclose improper conduct and protect those who do

We will keep all reports alleging or disclosing improper activities confidential to the extent possible

We will not tolerate any adverse action against an employee who makes a good-faith report or complaint about suspected violations


Whistleblower Protection (cont’d)

Whistleblower laws protect those who —

•Complain in good faith of illegal activity

•Lawfully attempt to stop illegal activity

•Participate in resulting investigation of illegal activity

We encourage employees to disclose improper conduct and protect those who do

We will keep all reports alleging or disclosing improper activities confidential to the extent possible

We will not tolerate any adverse action against an employee who makes a good-faith report or complaint about suspected violations


Pop Quiz!

Emilio suspected that his supervisor was engaging in Medicare fraud, but he wasn't sure and had no evidence. He was afraid that if he reported his supervisor and turned out to be wrong, he wouldn't be protected as a whistleblower. Would Emilio be protected if he reported his suspicions?

A. No, because he must be certain.

B.Yes, if his report is in good faith.

C.Yes, absolutely.

D.No, because he needs evidence.


Reporting Fraud

Employees, officers and directors all have a duty to report fraudulent activities

If reporting fraudulent activity to your supervisor is impractical or inappropriate —

•Report to Legal Department; or

•Report anonymously through our hotline

You also have a duty to cooperate in investigations of alleged wrongdoing if requested

Do not discuss allegations or investigation with anyone outside of investigative chain


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Final Quiz


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Questions?


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Thank you for participating!

This course and the related materials were developed by WeComply, Inc. and the Association of Corporate Counsel.

Documents

Copyright© 2011 WeComply, Inc. All rights reserved. 9/6/2015 Whistleblowing