False Claims Act

On February 8, 2006, President George W. Bush signed the Deficit Reduction Act of 2005 into law. The Deficit Reduction Act contains many provisions reforming Medicare and Medicaid that are designed to reduce program spending.

As an entity that offers Medicaid and Medicare coverage, TrueCare is required to comply with certain provisions of the Deficit Reduction Act. One such provision requires us to provide you with information about the Federal False Claims Act, state False Claims Acts and other state laws regarding Health Insurance Fraud. In addition, the law requires you and your contractors and agents to adopt our policy on fraud, waste and abuse when handling TrueCare business.

The Federal False Claims Act

Using the False Claims Act (the Act), you can help reduce fraud against the federal government. The Act allows everyday people to bring “whistleblower” lawsuits on behalf of the government, known as “qui tam” suits, against groups or other individuals that are defrauding the government through programs, agencies or contracts.

The False Claims Act applies when a company or person:

  • Knowingly presents a false or fraudulent claim for payment,
  • Knowingly uses a false record or statement to get a claim paid,
  • Conspires with others to get a false or fraudulent claim paid, or
  • Knowingly uses a false record or statement to conceal, avoid or decrease an obligation to pay or transmit money or property.

“Knowingly” means acting with actual knowledge or with reckless disregard or deliberate indifference to the truth or falsity of information.

The time period for a claim to be brought under the False Claims Act is the later of:

  • Within six years from the date of the illegal conduct, or 
  • Within three years after the date the government knows or should have known about the illegal conduct, but in no event later than ten years after the illegal activity.

Deficit Reduction Act

The Deficit Reduction Act (DRA) strives to eliminate fraud, waste and abuse from the Medicaid and Medicare programs. Providers also have the obligation to report any actual or suspected violation of funds either by fraud, waste or abuse.

Entities must have written policies that inform their employees, contractors and agents with the following:

  • The Federal False Claims Act and State Laws pertaining to submitting false claims
  • How providers can detect and prevent fraud, waste or abuse
  • Employee protection rights as whistleblowers

Whistleblowing

Employees (current or former) and others are encouraged to report instances of fraud, waste or abuse to the government, who may proceed to file a lawsuit against the entity accused of violating the False Claims acts. The whistleblower can file a lawsuit independently. Cases found in favor of the government will result in the whistleblower receiving a portion of the amount awarded to the government.

Protections for the whistleblower note that employees who have been discharged, demoted, suspended, threatened, harassed or otherwise discriminated against due to their role in disclosing or reporting are entitled to all relief necessary to make the employee whole, which includes:

  • Reinstated employment at the same level of seniority
  • Double the amount of back pay plus interested
  • Compensation for damages incurred by the employee due to the employer’s inappropriate actions

Affected parties who fail to comply with the Law will be at risk of forfeiting all Medicaid payments until complying. TrueCare will take steps to monitor TrueCare-contracted providers to ensure compliance with the Law.

TrueCare Policy

It is the policy of TrueCare to detect and prevent any activity that may violate the federal False Claims Act, or the state Medicaid fraud laws cited in this policy. If any employee, provider, delegated entity, subcontractor, or agent has knowledge or information that any such activity may have taken place, he or she should contact the Program Integrity department. Information may be reported anonymously.

In addition, federal and state law and TrueCare policy prohibits any retaliation or retribution against persons who report suspected violations of these laws to law enforcement officials or who file “whistleblower” lawsuits on behalf of the government. Anyone who believes that he or she has been subject to any such retribution or retaliation should also report this to the Program Integrity department by calling 1-833-230-2174 or emailing Fraud@MSTrueCare.com.