Maybe you are a nurse who has noticed something strange about the way your hospital is billing or a physician that realizes someone in billing upcoded certain procedures before submitting the claim. Those who witness fraudulent activities such as these and wish to report the matter must move forward carefully.
Legal tools are available to help better ensure you hold the wrongdoer accountable for their fraudulent activity. The False Claims Act (FCA) is one example. The FCA allows the government to impose liability on individuals and companies who knowingly submit false claims for payment to the federal government. These cases generally move forward after a witness to fraud, such as yourself, files a claim. If it appears valid, the government may join the case.
While the FCA is a powerful way to keep bad actors accountable, it is not an easy tool to use. A failure to move forward following proper protocol can result in a legal challenge and dismissal of the case.
What are common reasons for the dismissal of FCA cases?
One of the biggest errors is a failure to state a claim. To make a proper FCA case, an individual, often referred to as a whistleblower or relator, must provide specific evidence that demonstrates how a person or entity knowingly submitted false claims for government funds. The claim must generally detail the fraudulent activity, including who was involved, how the fraud was committed, and the financial impact on the government, while adhering to legal procedures for filing under the FCA.
Another common issue involves a case that violates one of the FCA’s many jurisdictional provisions. If this issue is present, the court may determine it has no jurisdiction over the case and dismiss it. These provisions are legal requirements that determine whether a court has the authority to hear a case. Key jurisdictional provisions under the FCA include the “public disclosure bar,” which prevents cases based on information already publicly disclosed unless the whistleblower is an original source, and the “first-to-file bar,” which prohibits multiple claims based on the same facts. To help better ensure compliance, a claimant should thoroughly research and verify that their information is not already publicly disclosed or previously filed.
How can I make sure my claim meets the requirements for an FCA case?
The initial hurdle is drafting a complaint that meets legal standards, particularly the heightened pleading requirements for fraud. Nex, to further mitigate the risk of dismissal, potential plaintiffs should make sure their complaint includes:
- Detailed factual allegations: As noted above, the complaint must describe the fraudulent scheme with particularity including who did what when and where. Vague or conclusory allegations are insufficient.
- Evidence of materiality: The false claim must have played a major role in the government’s payment decision.
- Knowledge of falsity: The plaintiff must demonstrate the defendant knowingly submitted the false claim. This includes actual knowledge deliberate ignorance or reckless disregard of the truth.
Meeting these requirements demands thorough investigation, careful documentation and an understanding of applicable laws and regulations.
Successfully navigating a False Claims Act case requires more than just suspicion of fraud. It demands a comprehensive understanding of the law, thorough preparation and the ability to articulate a compelling legally sound claim. Individuals contemplating an FCA action should seek experienced counsel to help better ensure their case can withstand scrutiny and potential motion to dismiss.