False Claims Act: Court Lets CNO’s Case Go Forward Over Forged Medicare, Medicaid Claims.

False Claims Act: Court Lets CNO’s Case Go Forward Over Forged Medicare, Medicaid Claims.

Legal Eagle Eye Newsletter for the Nursing Profession

May 2018

The US False Claims Act allows a private individual to file suit in the name of the US government to recoup payments made by the government to parties who have billed the government under false or fraudulent premises. If the facts underlying the suit can be proven, the private party stands to be awarded a percentage of what is recovered. UNITED STATES DISTRICT COURT DELAWARE March 30, 2018

A hospital’s chief nursing officer sued the hospital under the US and Delaware False Claims Acts (FCA) alleging that the hospital submitted false or fraudulent claims to the US government for payment under Medicare, Medicaid and the Federal employees’ healthcare system. The lawsuit focused on the fact the hospital’s director of health information had for some time been submitting claims for reimbursements bearing forged signatures of physicians and other practitioners.

The US District Court for the District of Delaware ruled that the basic legal theory of the case is valid and the case can go forward. Provider certification of the necessity for and performance of services is essential for reimbursement. Forgery of such certification is false and fraudulent conduct outlawed by the FCA.

The private party filing a FCA suit is entitled to a small percentage of the amount recovered on behalf of the government in a successful FCA lawsuit. A small percentage of a recovery potentially in the millions is the incentive intended by the law to motivate private citizens to come forward with cases of fraud against the government. The FCA also provides for the attorney representing the private party to add attorney fees into the recovery. That provides an incentive for attorneys to take such cases which can be difficult and time consuming and relieves the private party from paying a large portion of the reward to the attorney. US v. Hospital, 2018 WL 1568874 (D. Del., March 30, 2018).