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Nearly $2 billion recovered in healthcare False Claims Act cases in 2015, Justice Department says

The DOJ said whistleblowers filed 638 suits in 2015, garnering $2.8 billion in proceeds for the government.

Beth Jones Sanborn, Managing Editor

The Justice Department raked in more than $3.5 billion in 2015 in settlements and judgements from civil cases under the False Claims Act, including $1.9 billion in healthcare fraud settlements, Principal Deputy Assistant Attorney General Benjamin C. Mizer, head of the Justice Department's Civil Division, said this week. Since January 2009, the DOJ has recovered $26.4 billion, with the bulk coming out of healthcare cases.

Of the monies recovered in 2015, $1.9 billion came from cases related to the healthcare industry. They included companies or individuals who, according to the Justice Department, provided unnecessary or inadequate care, gave kickbacks to providers in exchange for providers using particular goods/services, or overcharged for goods/services from Medicare, Medicaid as well as other federal programs. The numbers reflect only federal loss. The Department says in many of these cases, they helped recoup millions at the state and consumer levels as well.

[Also: Running list of notable 2015 healthcare frauds]

Hospitals specifically were involved in $330 million worth of settlements/judgments this past year, including one whistleblower suit, in which a cardiac nurse and healthcare reimbursement consultant blew the whistle on hundreds of hospitals that they claimed were implanting cardiac devices in Medicare patients against specified criteria from CMS and health experts. The Department also saw several cases involving violations of the Stark law, which prevents inappropriate financial relationships between hospitals and providers that could potentially influence patient referrals. Medicare and Medicaid will not reimburse for services provided that violate the Stark Law. Finally, about $96 million in judgements involved claims against the pharmaceutical industry.

[Also: 457 hospitals settle for $250 million over improper implantable cardioverter defibrillator surgeries]

The Department says not only are these victories important in restoring assets and resources to federally-funded programs, but they also act as strong deterrents for others thinking of gaming the system.

"The False Claims Act has again proven to be the government's most effective civil tool to ferret out fraud and return billions to taxpayer-funded programs," said Mizer. "The recoveries announced today help preserve the integrity of vital government programs that provide healthcare to the elderly and low income families, ensure our national security and defense, and enable countless Americans to purchase homes."

The False Claims Act is the government's central civil tool in redressing false claims for government funds under all manner of government contracts including Medicare and Medicaid, national security and defense contracts, federally insured loans and mortgages, disaster assistance and other categories. Most false claims, the DOJ said, are filed under the Act's whistleblower provision, also called 'qui tam.' If the government wins, the whistleblower does too, receiving up to 30 percent of what's recovered. The DOJ said whistleblowers filed 638 suits in 2015, garnering $2.8 billion in proceeds for the government. The whistleblowers themselves took in $597 million.

Twitter: @BethJSanborn