In this episode of 1st Talk Compliance, Kevin Chmura is joined by Rachel Rose, JD, MBA, as they discuss the False Claims Act in detail. The FCA, one of five federal laws built to combat fraud, waste, and abuse, is the government’s primary fraud fighting tool, with the healthcare industry paying the largest contributor in recoveries for over a decade.

Learn not only about how to avoid running afoul of this law, but also some details of cases in which it was violated, and the repercussions those who did so faced. In addition, find out how a proper compliance program can protect your practice in various ways, including staying up to date on cybersecurity training.

Kevin Chmura

Rachel, welcome to the podcast. Thanks for joining us.

Rachel V. Rose

Thank you, Kevin, for having me back for another round of a very major healthcare compliance topic.

Kevin Chmura

It very much is, yeah. This one generates some revenue for the government. So this is one that I think especially in today’s environment, people should be paying a lot of attention to. So as I said in the intro, we’re here to talk about the False Claims Act. It’s one of the most important fraud, waste and abuse laws that applies to physicians and health care practitioners of all kinds.

The healthcare industry has consistently been one of the, if not the highest contributor to funds received under the False Claims Act. And it’s essential to be familiar with the law and maintain compliance programs to mitigate that risk. Rachel, I know you spend a fair amount of time in your practice in and around the False Claims Act defending and representing customers and providers.

So you’re perfect to cover this topic for us. Wondering, though, if you could give us a brief synopsis of the False Claims Act and why is it unique?

Rachel V. Rose

Absolutely. So as you mentioned, my practice focuses a lot on the False Claims Act, and I am fortunate to do a lot of compliance work not only around the False Claims Act, but HHS. OIG has identified five important federal fraud, waste and abuse laws. The False Claims Act, the Anti-Kickback Statute, the Stark Law, the Exclusion Authorities, and the Civil Monetary Penalties.

And Kevin, as you mentioned, the False Claims Act is really the federal government’s primary fraud fighting tool. And in 2024, there were more than $2.9 billion in recoveries and, moreso healthcare represented over two thirds of that amount. That healthcare trend, as you mentioned, being the largest contributor, has gone on for at least the last decade.

And what the False Claims Act does that makes it unique are really, I would say, five main things. But first, the False Claims Act goes back to 1863, and it is also known as the Lincoln Law. Its primary purpose, even back during the Civil War, was to root out fraud that was being perpetrated on the government. So how would that be done?

Congress thought about it and said, well, the government could do it on its own if they caught wind of something, or they could insert a provision which gave an individual known as a relator, also known as a whistleblower, the potential to bring fraud to the government’s attention and receive a portion of the recovery. It’s very important to note that a relator and I represented several relators successfully, sometimes with co-counsel, sometimes with not, so I get to see the False Claims Act from the whistleblower standpoint as well. But this notion of being able to represent a whistleblower is the first distinguishing factor. And that’s because most other civil cases, a person can represent themselves on a pro say basis, meaning they don’t need a lawyer. There was a provision in the False Claims Act which in fact requires an individual to be represented by a lawyer.

So unless the relator is a lawyer, then the individual needs to obtain counsel in order to file a False Claims Act case. That’s the first thing. Secondly, only the government can choose to open a criminal investigation. So even though certain laws like the federal Anti-Kickback Statute can have criminal penalties or civil penalties associated with them, only the federal government, or if a state has a similar type of law, the state can actually move and bring a parallel criminal investigation in potential proceeding.

So that notion that only the government can bring in a criminal case is not unique to the False Claims Act. But what is unique is that a private party can bring a type of case, and that’s how the government learns of something to then potentially open a parallel criminal action. The process for the relator’s counsel is also very different.

Normally, if I want to file a lawsuit in federal district court, I have to make sure that either a federal question is involved under 1331, or I need to meet the amount in controversy and diversity of the party’s requirement under 1332. While first, the False Claims Act is a federal statute, so it falls under 1331. So that’s the same.

What is not the same is that before I even file a case under seal in a United States District Court, I have to provide a disclosure in evidence to the local United States attorney where I’m going to file the case, as well as providing that same information to Main Justice in Washington, D.C.. Another area that is relevant that I just mentioned is the seal.

So that’s the third item. And initially, the statute itself provides for 60 days that the case is filed under seal, meaning no one knows about it but the relator, the lawyers, the judge, and whatever the court staff are, and that’s the way it has to stay. Now, the government may request what are known as deal extensions in this type of case.

And another provision relates to the breaching of the seal. In the 2016 Supreme Court case, Rigsby versus State Farm, is the case that outlined different fact orders, which first stated A. Just because there may be a seal breached doesn’t mean that the case is automatically dismissed. But the court said we get to apply these factors and make that determination.

I will say that even if the court says no, this case doesn’t need to be dismissed and the Government agrees with that, that the government on the back end, when we start to get to the fee issue where the relator can recover, they, the government, has the right to drop the recovery. If there has been a breach of the seal below what the typical statutory threshold is, and I’ll get to that in a moment.

The other distinguishing factor in a False Claims, that case is once I filed the case, it’s really in the government’s hands until they make a decision. And there are three ways a case can go. The government can intervene in the case and intervention can occur at different times. I’ve had cases that have settled under seal and then the intervention decision is made and the seal is lifted by the court, so the government has taken the case through settlement, even though there has not been any action in court, so to speak.

The second way to intervene is that if the defendant won’t settle while the case is under seal, the government can say, Hey, all right, relator, we like the case, we have adequate resources. And I don’t necessarily mean monetary resources. I made the specific notion of adequate human resources, right? Because the government only employs so many people and so many assistant U.S. attorneys to work on these cases. So the Georgia Tech case is an excellent example where the government intervened and they’re the ones who are leading trial.

So in that instance, the relator’s counsel and the relator just sit back, and if the government needs help with something, then they’ll ask. Declining to intervene means that the government is not going to intervene, but they say to myself or other relator’s counsel, if you would like to move forward with the case and prosecuted, you’re able to. And so I’ve had that scenario as well. And then lastly, they can dismiss the case under C two way, and that’s always the government’s discretion.

And the Supreme Court case, the Polansky case is a case from 2023 that actually addressed that very issue. Now, penalties and damages, damages can be trebled under these circumstances. Penalties up until 2016 ranged from $1500 to approximately, not  $1500, $5500 to approximately $11,000 per violation. So that was per healthcare claim. Now the absolute minimum is over $11,500, and the upper end of that penalty range per claim is closer to $25,000.

Oftentimes we don’t see penalties assessed unless a case goes all the way through to verdict in a trial. But it can still be costly for damages being trebled depending on the type of case. The relator’s recovery, if the government intervenes in the case, is between 15 to 25% of the total recovery. If the government declines, then the relator is entitled to 25 to 30% in the event of a successful recovery. And it’s important to note that the False Claims Act is not an intent based statute.

Kevin Chmura

So. Well, wow that was great, that’s so, it’s dense, right. And there’s, yeah there’s a lot there, and expensive for those that find themselves on the wrong end of this, and so super important. And you touched on I think a few of them but I wonder if you could zero in a little bit on what healthcare laws are often included in False Claims Act cases.

Rachel V. Rose

Sever