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False Claims Act
Under the Deficit Reduction Act of 2006, CareSource is required to provide information about the federal False Claims Act, state False Claims Acts, and other state laws regarding Medicaid fraud.
The Federal False Claims Act
The federal False Claims Act (the “Act”) was first signed into law in 1863, but the Act underwent significant changes in 1986. Using the False Claims Act, you can help reduce fraud against the federal government. The Act allows everyday people to bring “whistleblower” lawsuits on behalf of the government- known as “qui tam” suits- against groups or other individuals that are defrauding the government through programs, agencies, or contracts.
The False Claims Act applies when a company or person:
- Knowingly presents a false or fraudulent claim for payment,
- Knowingly uses a false record or statement to get a claim paid,
- Conspires with others to get a false or fraudulent claim paid,
- Knowingly uses a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property.
“Knowingly” means acting with actual knowledge or with reckless disregard or deliberate indifference to the truth or falsity of information.
An example would be if a health care provider, such as a hospital or a physician knowingly “upcodes” or overbills; resulting in overpayment of the claim using Medicaid dollars.
With the 1986 Amendments, the incentives for private citizens to bring False Claims Act cases have increased, along with the consequences of committing fraud. Both of these moves were done in the hopes of preventing fraud.
The time period for a claim to be brought under the False Claims Act is the later of:
- Within six years from the date of the illegal conduct, or
- Within three years after the date the Government knows or should have known about the illegal conduct, but in no event later than ten years after the illegal activity.
Ohio State Law
While Ohio has not passed its own false claims statute, there may nevertheless be liability under various Ohio laws regarding false or fraudulent claims with respect to Medicaid program expenditures, including:
CareSource Policy
It is the policy of CareSource to detect and prevent any activity that may violate the federal False Claims Act or the state Medicaid fraud laws cited in this policy. If any employee, provider, delegated entity, subcontractor or agent has knowledge or information that any such activity may have taken place, they should contact the Special Investigations Unit. Contact information for Special Investigations is shown below. Information may be reported anonymously.
In addition, federal and state law and CareSource policy to prohibit any retaliation or retribution against persons who report suspected violations of these laws to law enforcement officials or who file "whistleblower" lawsuits on behalf of the government. Anyone who believes that he or she has been subject to any such retribution or retaliation should also report this to the Special Investigations Unit.
Special Investigations Unit Contact Information
CareSource Ohio
Anonymously:
Fraud Hotline: 800-488-0134, Ext. 2300
Fraud Fax: 800-418-0248
Written Report: Use the Fraud Reporting Form
Other means of contact that are not anonymous:
Fraud E-Mail: fraud@csmg-online.com
Click here for more information on our Fraud program.
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