Under the U.S. False Claims Act (FCA), any individual or entity that knowingly keeps an overpayment or submits a false or fraudulent claim for payment of U.S. Government funds can be held liable for significant penalties and fines. The FCA applies to claims by health care organizations to Medicaid, Medicare, and other government sponsored health care programs. Potential fines for violating the FCA include a penalty of: (1) up to three times the amount of the damages sustained by the government for each false claim; (2) additional civil penalties for each false claim; and (3) payment of the cost of the civil action by the entity or individual that submitted the false claims. Criminal penalties may also apply. If found liable under the FCA, the entity or individual may also be excluded or suspended from participating in all federal health care programs.

The FCA contains “whistleblower provisions” that allow people with evidence of fraud against the government to sue, on behalf of the U.S. Government, in order to recover the stolen funds. In some cases, the U.S. Government may join the whistleblower suit. If a whistleblower suit is ultimately successful, the person who initially brought the suit may be awarded a percentage of the recovered funds.

The FCA also contains a provision that protects the whistleblower from retaliation by their employer. This provision applies to any employee who is discharged, demoted, suspended, threatened, harassed, or discriminated against as a result of the employee’s lawful acts in a whistleblower suit. Centene affords employees all protections required by the FCA.

In addition to the U.S. FCA, a number of U.S. states and other countries also have false claims legislation with similar penalties that work to discourage fraud perpetrated against local governments.

Make a Report

Any reports of potential bribery or corruption will be considered confidential unless disclosure is required by law. U.S. federal law protects “whistleblowers” who report, in good faith, these types of issues, and the law prohibits retaliation against such individuals. Employees should follow their business unit’s reporting procedures when making reports. In the U.S., the toll-free Ethics & Compliance helpline (1-800-345-1642) is available to employees, members, patients, business partners, and network providers to make anonymous reports. Ribera Salud employees may e-mail: compliance@riberasalud.es and Operose Health employees may e-mail: governance@operosehealth.co.uk.