...Running head: FALSE CLAIMS ACTS: 1 SHOULD THEY BE SEALED? False Claims Acts: Should they be sealed? Becky L. Garcia Abstract Throughout history the United States Government has been responsible for massive expenditures for government operations involving taxpayer dollars. Unfortunately, with all the different organizations and transactions transpiring, there have become endless opportunities for fraud or deceptive practices. The government enacted the False Claims Act for help in controlling the deceptive practices and additionally giving them a viable tool to expose the fraudulent acts. The False Claims Act allows a whistleblower or “qui tam” to come forward and help aide the government with the massive ongoing fraud that is enacted everyday against the government. A much needed provision that helps ‘seal’ and protects the whistleblowers identity was added into the FCA. The protection by sealing the name when a claim is enacted by a whistleblower is important because it allows the whistleblower to help the government with the pursuit of fraud while protecting the whistleblower from backlash from their employee or organization. There are many organizations within the Government that spend an enormous amount of taxpayer dollars. From within these organizations fraud and deceptive practices are found, and sometimes are a regular practice in everyday expenditures. The Government cannot stop or find all of the illegal practices going on within, but for...
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...MGMT. 703 – 101 Ethics & Stakeholder’s Management Individual Assignment # 1 The Travel Expense Billing Controversy and The False Claims Act 1. Why would an independent audit firm, like PwC, that depends upon the maintenance of its reputation for integrity and professionalism, to retain and attract clients, risk the loss of that reputation by engaging in what appears to be unethical behavior (not returning travel expense rebates)? Explain your answer and reasoning. * Pricewaterhouse Coopers (PwC) is a major accounting firm and has a strong foothold in financial markets. The company remarked that their employers were engaged in unethical billing practices through which they are earning millions of dollars. The company was earning huge rebates on airline tickets and other travel expenses that were being charged to different clients associated with the company. The firm’s Global-Travel director replied it as, the negotiations were associated with the travel deals and not with the clients, so in this case any rebates or discounts earned are company’s profit. The company failed to attain integrity and industrial professionalism by committing this unethical practice for their own advantages. The company was greedy in earning profits through unethical practices and overlooked the reputation of the company in front of their clients and the overall financial market. It was not the company as a whole, but some of its senior executives who were not loyal and honest...
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...The first law implemented to combat fraud and abuse in general was the False Claims Act of 1863. This act prohibits defrauding the federal government through the act of charging for services that were not provided, and gives the opportunity for whistleblowers to take action against those guilty of fraud and to receive a share of the money that is recovered. Amended in 1986, the False Claims Act had recovered $40 billion, and although this act was not specifically created for health care, half of these recoveries came from health care cases. Over 100 years later, the Social Security Act of 1965 imposed penalties on those who engage in improper conduct in a federal health care program and prohibited their further participation in these programs....
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.... The term reimbursement refers to repayment or compensation of health care services (Bowman, 2007). Reimbursement is the process of being repaid for services that have already been given (Casto, 2006). In long term care, services are often provided prior to payment being made. Since patients have already received treatment, the facility, practitioners, and their staff seek reimbursement to cover those expenses such as medications, procedures, and supplies (Bowman, 2007). Generally a physician, health care organization, or practitioner will submit an itemization of services, products, equipment, and supplies that have been rendered (Casto, 2006). This is known as a claim (Casto, 2006). The claim lists the fundamental characteristics of reimbursement such as fees and charges (Casto, 2006). These claims are reimbursed by one of two ways. An institution can be paid by a fixed amount called capitation (Casto, 2006). A capitated amount is what is paid regardless of the number or costs of health care services provided (Bowman, 2007). This often gives providers incentive to lower costs and to focus more on preventive care (Bowman, 2007). Fee for Service is another method of reimbursement. This is paid based on a set fee for each service provided (Casto, 2006). The set amount is based on what the payer deems as a normal charge for that service (Bowman, 2007). Fee for Service gives providers incentive to work harder and to provide a better quality of care that people want...
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...THE TRAVEL EXPENSE BILLING Act The Travel Expense Billing Controversy and False Claims Act PricewaterhouseCoopers LLP (PwC), a major accounting firm, was engaged in unethical billing practices that generated millions of dollars in additional revenue to the company. PwC was charging its clients the full price of airline tickets and other travel expenses, such as hotel rooms and car rentals, while it was actually expending only a small percentage of the full amount billed to its clients due to applied rebates and discounts it received under travel agencies and airline contracts and negotiations. Therefore, the company was “overcharging… clients and pocketing the difference without revealing the practice” (AccountingWeb). However, since Neal A. Roberts, a PwC employee, discovered his employer’s travel billing practices, PwC found itself in a very difficult situation. Mr. Roberts wasn’t in agreement with his company’s billing method and made several attempts to address the problem while working for his firm without much success. He reached out to the company’s ethics department and to an in-house PwC lawyer, but only managed to have the company’s policy revised, not corrected. A group of people (mostly the company’s partners) decided that under the new policy, PwC would have to disclose most of the discounts to its clients but still keep 8 percent of the rebates as a “cover our costs” fee while retaining the “millions… collected previously on the earlier rebates”...
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...The False Claims Act The False Claims Act, enacted by Congress in 1863 to protect the Union troops from profiteers providing shoddy goods and rotten food during the Civil War, prompted Abraham Lincoln's drive to empower private citizens with the ability to file suit on behalf of the government against corrupt contractors. The act was revitalized in 1986 to combat fraud in the defense contracting industry. Today, the False Claims Act is the government's principal weapon in the prosecution of health care fraud. One may be held either civilly or criminally responsible for knowingly or recklessly submitting a fraudulent claim to the government. The statute permits private citizens, or relators, to file a civil action against any entity or individual violating its provisions. Violators are subject to treble damages plus civil fines of not less than $5,500 but not more than $11,000 per claim. Under the criminal statute, false claims are punishable by fine or imprisonment of up to five years, or both, for knowingly submitting a false statement for reimbursement. To prevail under the False Claims Act, the government or its relator must establish that: the defendant presented or caused to be presented a claim to the government for payment or approval; the claim was false or fraudulent; and the defendant knew that the claim was false or fraudulent. "Knowing" means actual knowledge of false information, or acts in deliberate ignorance or reckless disregard of the truth or falsity of the...
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...The False claim act is a law that inflicts liability on an individual or company that takes advantage of governmental programs. With the False Claim Act individuals are able to recover money stolen through fraud (False Claims Overview, 2014). According to the Office of Inspector general in order to qualify for financial incentives a state’s false claim act must: • Establish liability to the state for false fraudulent claims • Contain provisions that are at least as effective in rewarding and facilitating qui tam actions for false or fraudulent claims as described in the FCA • You must contain a requirement for filling an action under seal for 60 days • Finally you must contain a civil penalty that is not less than the amount of the civil penalty (State False Claim Act Reviews, 2014). The Health Insurance Portability and Accountability Act (HIPAA) was designed to protect patient privacy. The three objectives that HIPAA was designed to accomplish are: • Determine the circumstances in which protected patient health information is used and disclosed • Establish individual rights in regards to protected information • Ensure that administrative safeguards are adopted to ensure the privacy of patient information Stark law forbids a physician from making certain referrals for certain designated health service (Physician Self Referral, 2014). Ten specific DHS services are as follows: • Clinical laboratory services • Physical Therapy services • Occupational Therapy services ...
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...shamed many organizations. Research suggests that it’s usually very difficult to report wrongdoing in organizations (Trevino, 2015). Among the main reasons people fail to report are fear of retaliation for reporting, and the belief that nothing will be done. Equally, those who do report say that they did so because they felt supported by managers and coworkers, they believed something would be done, and they were able to report anonymously (Trevino, 2015). For those who do report, most people prefer to handle issues within the organization before venturing outside, and most will go to their direct supervisor first (Trevino, 2015). Recently, protection for certain types of whistleblowing has increased with legislation such as the U.S. False Claims Act, Sarbanes-Oxley and the creation of the Office of the Whistleblower by the Securities and Exchange Commission (SEC). Whistleblower Due To Receive $63+ Million Reward Keith Edwards, a former J.P. Morgan employee is due to receive a nearly $64 million payment from the U.S. government for the tips he provided as a whistleblower. According to (Veire, 2014), Mr. Edwards provided information that led to a payment by J.P. Morgan...
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...officials, government authorities, and the media. Some of the key characteristics of a whistleblower are that they are altruistically motivated, utilitarian, uninterested in altering their behavior and they allow their own attitudes and beliefs to guide them. Most whistleblowers are often well-educated and hold professional positions (Wines, 2005). JP Morgan Whistleblower According to a Reuters article a JPMorgan whistleblower was compensated $63.9 million in a mortgage fraud deal. “Keith Edwards, a Louisiana resident, had worked for JP Morgan or its predecessors from 2003 to 2008, and had been an assistant vice president supervising a government insuring unit” (Stempel, 2014). Edwards originally sued JPMorgan in 2013 under the False Claims Act, which allows individuals to be able to sue government contractors and suppliers for allegedly defrauding taxpayers. The U.S. Department of Justice also joined as a plaintiff in this case. JPMorgan actually admitted that “for more than a decade,...
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...Federal Laws and Regulations Health Services Finance 05/08/2016 Federal Laws and Regulations The False Claim Act is a federal law that makes it a crime for any person or organization to knowingly make a false record or file a false claim regarding any federal health care program, which includes any plan or program that provides health benefits, whether directly, through insurance or otherwise, which is funded directly, in whole or in part, by the United States Government or any state healthcare system. What are five elements pertaining to the establishment of a false claim under the False Claims Act? Under whatever section of the Act, the government or a qui tam plaintiff must prove the following: (1) that the defendant presented or caused to be presented to the United States government a claim for payment or approval, or a document to facilitate the payment of a false claim; (2) that the claim and/or document was false or fraudulent; and (3) that the defendant knew that the claim was false or fraudulent or acted with reckless disregard of the truth or falsity of the claim. If these elements are present, a violation of the FCA occurs even if the government never actually makes any payment or suffers a financial loss. The defendant does not have to act with a specific intent to defraud in order to be liable, as long as the submission was "knowing." HIPAA privacy standards were designed to accomplish what three broad objectives? The HIPPA privacy standards are intended...
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...Financial Laws Theodore Gladney Health Services Finance Professor: Alison Williams Financial Laws Five Elements Pertaining To the Establishment of a False Claim under the False Claims Act The five elements necessary to establish a false claim must determine that the claim was in breach of State laws. It must be proved beyond reasonable doubt that the claim was false, fraudulent or fictitious and made for a monetary benefit. The false claim is established when an individual is in possession of a property or money used by the government with the intention to defraud the government (Boese, 2005). It must also be established that the ‘false claim’ was made with actual knowledge. False certification of receipt of property without attempting to confirm the truth of the information provided is also an element that constitutes false claim. Three Broad Objectives of HIPAA Privacy Standards HIPAA privacy standards aims to achieve the following three important objectives: i) Administrative Safeguards HIPAA privacy rules designed procedures and policies regarding the administrative procedures of the act; how will the act be complied with. ii) Physical Safeguards HIPAA privacy rules were designed to control physical access to guard against inappropriate access to personal healthcare information. iii) Technical Safeguards HIPAA privacy rules control access to computer systems and facilitate enclosed entities to protect interactions involving PHI transmitted...
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...Financial Laws and Regulations Tayyaba Baig Devry Fresno HSM 340 July 14, 2013 Ms. Mary Financial Laws and Regulations 1. What are five elements pertaining to the establishment of a false claim under the False Claims Act? According to our text, the five elements pertaining to the establishment of a false claim under the False Claims Act are the government should establish the claim was false and submitted knowingly, government must establish that the person submitted the claim with actual knowledge, in deliberate ignorance, or with reckless disregard for the claim’s truth, or falsity. (Cleverley 90) 2. HIPAA privacy standards were designed to accomplish what three broad objectives? Explain each. The three broad objectives HIPAA privacy standards were designed to accomplish are limit the circumstances in which individuals use and disclose patient health information, establish individual rights regarding patient health information, and require protected individuals to adopt administrative safeguards to protect the confidentiality and privacy of patient healthcare information. According to our text, HIPAA prohibits the disclosure of any individual health information that is transferred or maintained electronically such as emails and faxes. HIPAA privacy standards also ensures that individuals have right of deciding which information should not be disclosed under any circumstances. Finally, HIPAA privacy standards also ensure that all security standards are...
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...Financial Laws and Regulations DeVry University HSM 340 Professor Black Financial Laws and Regulations 1) There are five elements that pertain to the establishment of a false claim under the false claims act. The first element that is identified by Cleverley et al (2011, p.90) is that the false claim act is that the claim, either to receive payment or to not pay the government, must be established as false. The second element that Cleverley et al states is that must be identified is that the claim was submitted knowingly that it was false. The third element that they identify is that the false claim can be submitted even in deliberate ignorance. The fourth element is that the false claim can be submitted with disregard of the claims falseness, or truth in recklessness. Lastly Cleverley et al explain that the person, or persons, that file a fraudulent claim will be liable for $5,500-$10,000 per claim, plus up to three times the damages to the federal program. 2) The three broad objectives that HIPAA privacy standards were designed to accomplish are firstly to force any entity that has private health identifying information available to be forced limit use and to use that information wisely. What this means is that another medical facility, or lawyers office cannot just call/fax requesting information and require for it to be released without a signed consent form. Secondly, set specified standards as to the patients’ rights to keep their information private. An example...
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...approved for Medicare. This is hurting the people who truly need Medicare. Nature of Medicare fraud and abuse laws Medicare fraud and abuse is when someone will make false statements about themselves or that someone else is giving false information so the other person can get Medicare. When Medicare fraud happens it can either be a one person act or from a group of people or even an organization. Many people around commit fraud, in fact you may know someone who has already done so or may do so. “Organized crime is infiltrating the Medicare Program and masquerading as Medicare providers and suppliers” (Department of Health and Human Services, 2012). Some forms of Medicare fraud are: When someone is billing for services but there were no supplies that were available or services, when someone has billed Medicare for appointments that weren’t made, when someone changes claim forms or makes changes to receipts in order to get higher payments. Medicare abuse is when there is unnecessary cost in Medicare. “Abuse includes any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and are fairly priced” (Department of Health and Human Services, 2012). Some examples of Medicare abuse is: When claims are changed with different codes, when supplies and services are overcharged, and when services were billed when it wasn’t necessary. When Medicare fraud and abuse...
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...Assignment 1 – Whistleblowing and Sarbanes-Oxley Tialia Booth LEG 500 – Law, Ethics, & Corporate Governance Strayer University Professor Lateefah A. Muhammad July 20, 2015 Whistleblowing and Sarbanes-Oxley Peter Buxtun. Linda Almonte. John Kopchinski. Edward Snowden. Everett Stern. J. Kirk McGill. The commonality in each of the individuals listed is that they have been identified as a whistleblower. This paper will review the key characteristics of a whistleblower, examine an example of whistleblowing from recent history, provide an opinion on whether or not such whistleblowing was justified by the individual, and finally review the current Sarbanes-Oxley Act to determine to what extent the individual was protected. A whistleblower can be most basically defined as an individual or persons who report and make known unethical and illegal actions taken by their employer. The employer could be a publicly traded or privately held company or a not-for-profit organization. The whistleblower may choose to release their findings and information uncovered within their own company or to outsiders such as the news media, law enforcement officials, or federal regulators. In every case of a whistleblower coming forward there is a shared desire to stop the unethical and possibly illegal behavior or acts being committed and to ensure those who have been affected are identified and hopefully compensated or righted in some way (Halbert, Ingulli, & Frey, 2015). In 2003...
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