Federal and state officials have uncovered billions of dollars in healthcare fraud under the False Claims Act. This statute allows for private citizens, known as qui tam plaintiffs, to sue as whistleblowers on behalf of the federal government. A qui tam a action is designed to not only help the U.S. recover money lost to fraudulent schemes, but also to provide an incentive for the public to come forward with information about fraud; a sizable recovery of up to 20 percent for the plaintiff – who is also known as the relator. In a new bill introduced to the House of Representatives on August 1st of this year, hospitals are being offered a reprieve from full-scale investigations into what may be innocent billing errors without the government first certifying that the regulations cited and False Claims Act are relevant. The bill is designed to reduce the costs associated with a hospital having to commence internal investigations over every allegation of healthcare fraud. The fear, however, is that legitimate concerns over billing fraud may fall under the radar or, at the least, face significant delays in prosecution.
Introduced by Representatives Howard Coble (R-NC) and David Scott (D-GA), the Fairness in Health Care Claims, Guidance and Investigations Act (“HR 2931”) is offered to “amend the false claims provisions of title 31, United States Code, with respect to health care programs, and for other purposes.” More specifically, the bill as drafted would require the Attorney General to certify in writing that every agency responsible for enacting billing regulations has examined these regulations, guidelines and billing instructions as relevant to the allegations before requesting any information from a physician, hospital, or other provider health care service, in connection with an investigation concerning 10 or more claims submitted to a Federal health care program. The Attorney General must further certify that agency officials have determined, after reviewing the regulations, that the allegations are still valid and that the False Claims Act actually applies to the investigation.
Aside from Hospital Administrators, Who Does This Bill Help?
It is difficult to imagine how a bill requiring professional federal investigators to stop and read their statute books before every investigation can actually help alleviate fraud in the healthcare sector. Not only does this proposed legislation force the imposition of significant delays, it could also provide fraudulent healthcare providers an opportunity to doctor evidence in preparation for an upcoming investigation.
In support of HR 2931, hospitals are asserting that the complexity of billing codes and volume of patient invoices make it easy to make simple mistakes when sending bills to Medicare and Medicaid. These entities believe this legislation will help avoid inquiries into these simple mistakes, thereby saving administrative time and resources.
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