False Claims Act

Legal Considerations for Healthcare Billing

Published on: April 25, 2025 | By Conaway & Strickler, P.C.

Billing to the United States government presents a unique set of legal requirements for healthcare professionals. Physicians who participate in federal healthcare programs like Medicare and Medicaid are subject to strict billing regulations. Even inadvertent errors can lead to severe legal consequences, including criminal charges. Understanding these laws and the potential risk of noncompliance is crucial for healthcare providers.

When the federal government is paying for items or services rendered to Medicare or Medicaid beneficiaries, federal fraud and abuse laws apply. Healthcare professionals influence what services patients receive and are responsible for the documentation of those services. That documentation is the basis for bills sent to insurers, and ultimately, the Government’s payment of a beneficiary’s medical claims.

If a physician knew or should have known that the submitted claim was false, the attempt to collect unearned money constitutes a violation. Federal fraud and abuse laws include the following:

Deferred Prosecution Agreements in the Health Care Field

Published on: March 8, 2025 | By Conaway & Strickler, P.C.

The federal government may target organizations and businesses as well as individuals for violations of federal criminal statutes. For example, in the health care realm, cases can include office managers, practitioners from doctors, nurses to pharmacists to all other aspects of the medical industry. Recent federal investigations have targeted pill mills, medicaid fraud, and accepting kickbacks among others.

Experienced federal criminal defense attorneys like those at Conaway & Strickler, PC may suggest early on about the possibility of entering into a “deferred prosecution agreement” which is essentially a contract with the Department of Justice. DPAs are frequently used in cases involving corporate fraud, bribery, and antitrust violations. These pretrial agreements may involve an admission of wrongdoing, the payment of fines, and the implementation of compliance measures. Charges may be dropped if the defendant complies with the requirements of the agreement. Generally, the Assistant United States Attorney will file the criminal complaint and the DPA with the court, so it is of public record. This will be accompanied by a formal request to the court that any prosecution be delayed according to the terms of the DPA, allowing the defendant to fulfill its agreed-upon actions. This is very similar to conditional discharge / pre trial diversion agreements found at the state level.

An example of a DPA would be one that was entered in to by the DOJ and Teva Pharmaceuticals USA, Inc in August 2023 in response to the company’s involvement in a price fixing conspiracy involving several pharmaceuticals. As seen in this example, terms can include paying a fine, waiving certain rights, agreeing to a factual basis for the charges, and an agreement to cooperate and compliance monitoring and of course, agreeing to what will happen if there is a breach of the agreement.

Recent Overview of the False Claims Act

Published on: April 16, 2024 | By Conaway & Strickler, P.C.

Settlements and judgments under the False Claims Act have reached a unprecedented high in the United States. According to the Department of Justice in a press release, there were 543 settlements and judgments in the 2023 fiscal year, which exceeded over $2.68 billion. In the release, Principal Deputy Assistant Attorney General Boynton states “As the record-breaking number of recoveries reflects, those who seek to defraud the government will pay a high price.”

The False Claims Act (FCA), also known as the “Lincoln Law,” is a federal law that imposes liability on individuals and companies who defraud governmental programs. This includes submitting false invoices, making false statements to get paid by the government, or avoiding payment of money owed to the government. The law was originally enacted during the Civil War to combat fraud by government contractors supplying the Union Army with substandard goods; however, the FCA was strengthened in 1986, when Congress increased incentives for whistleblowers to file lawsuits alleging false claims on behalf of the government.

Under the FCA, individuals or entities can be held liable for knowingly submitting false or fraudulent claims for payment to the government. The FCA allows private individuals, known as “whistleblowers” or “relators,” to file lawsuits on behalf of the government and share in any monetary recovery. These lawsuits are known as qui tam actions. If the government intervenes in the lawsuit and recovers funds, the whistleblower is typically entitled to receive a portion of the recovered amount, often ranging from 15% to 30%. In fiscal year 2023, whistleblowers filed 712 qui tam suits, and this past year the Justice Department reported settlements and judgments exceeding $2.3 billion in these and earlier-filed suits.

What are the current DOJ priorities?

Published on: April 1, 2022 | By Conaway & Strickler, P.C.

Attorney General Merrick Garland made recent comments about what he considered to be the Department of Justice’s top priorities for 2022. Since taking office in March 2021, Garland has tried to combat crime in a tumultuous time. He has been criticized for his handling of January 6 investigation and has stated it’s the most urgent probe in history.

With all of this going on, the US Attorney’s office increased its prosecutions of individuals of white collar crimes in the year 2021. White collar charges like fraud, theft, corruption, bribery, environmental crime, tax fraud, health care fraud, procurement fraud, money laundering, PPP loan fraud, etc will continue to get more attention from the Department of Justice.

What does this mean? It means that investigations of any sort need to be taken seriously and that you should contact a lawyer immediately if any wrongdoing is alleged.

Whistleblower / Qui Tam cases in Health Care

Published on: September 11, 2021 | By Conaway & Strickler, P.C.

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Health Care Qui Tam cases

What does Qui Tam mean?

Qui tam is short for the Latin phrase “qui tam pro domino rege quam pro se ipso in hac parte sequitur,” which roughly translates to “he who brings an action for the king as well as for himself.”

False Claims Act – How to Defend Against the Government

Published on: April 26, 2016 | By Conaway & Strickler, P.C.

False Claims Act – Has the state or federal government reached out to your professional office alleging violations of the False Claims Act? Call Conaway & Strickler, PC as soon as possible if so. It is imperative to have help at the first indication that the government is looking into your billing for Medicare. Are they alleging upcoding? Overbilling? Phantom billing? The U.S. Attorney’s Office and /or the State will attempt to sue you under the False Claims Act, but also, will attempt to bring criminal charges. They may be alleging that some billing was not done in compliance with Medicare rules. Having a lawyer involved will help throughout the process and can dramatically reduce the amount the government alleges were wrongfully billed.

Physicians and practice groups that have either received a letter or a “knock and talk” from the government should not attempt to deal with the allegations of improper billing without legal help. We can help you show the government that the all costs billed to Medicare were for services provided and that no costs were inflated. We can also enter into negotiations to settle claims of violations of the False Claims Act with the Department of Health and Human Services and the Officer of the Inspector General.

The government has worked hard in recent years in combating health care fraud under the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced by the Secretary of the Department of Health and Human Services in May 2009. And one of the most powerful tools in the government’s arsenal is the False Claims Act.