decisionhealth Newsletters, Answer Books - 2009 Issue 3 (March)
False Claims Act / Legal and factual predicates
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Article Overview
This article covers the Department of Justice’s framework for assessing whether there is enough legal and factual support to proceed with a False Claims Act case involving health care claims. It is aimed at readers who need a general understanding of the investigative and evidentiary factors considered by U.S. Attorneys, including claim falsity, knowledge, notice, compliance efforts, prior audits, and agency guidance. The discussion is relevant to compliance, auditing, enforcement, and legal review involving Medicare and related government health programs.
Why This Topic Matters
It helps readers understand the kinds of issues prosecutors weigh before bringing a False Claims Act matter, which is important for compliance teams, auditors, legal counsel, and health care providers monitoring billing risk.
What You Will Learn
- What DOJ considers before alleging False Claims Act violations
- How prosecutors assess whether a factual and legal basis exists for a case
- What kinds of evidence and background factors may be reviewed in billing investigations
- How provider knowledge, compliance efforts, and prior government interactions may be evaluated at a high level
Who Should Read This
- Health care compliance professionals
- Medical billing and coding staff
- Health care attorneys
- Auditors and investigators
- Provider leadership
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