Perhaps the most powerful tool available to the United States in its efforts to combat fraud against the government is the Federal False Claims Act (FCA). The Department of Justice has recovered billions in fraudulent billings through the prosecution of FCA cases, many of which were aided by qui tam whistleblowers.
The FCA allows citizens who discover that companies are committing fraud against the U.S. to sue on behalf of the government through what are known as qui tam lawsuits. Qui tam is short for a Latin phrase that means “he who sues on behalf of the King as well as for himself.” Qui tam actions were widely used in Europe during the Middle Ages, since there were no official police systems and citizens were encouraged to maintain law and order on behalf of the King. In 1863, President Lincoln adopted this concept when the FCA was enacted in an effort to stop war profiteers from defrauding the Union during the Civil War.
When a citizen files a qui tam lawsuit on behalf of the government, that citizen is called a whistleblower or “relator.” Under the qui tam provisions of the FCA, relators may receive between 15 to 25 (and, in some cases as much as 30) percent of funds recovered by the government in successful enforcement actions. By creating this incentive for citizens with evidence of fraud to file qui tam lawsuits on behalf of the U.S., the law enhances the government’s ability to investigate fraud claims that it would not otherwise know about. This partnership between the government and qui tam whistleblowers has been a very powerful tool in fighting fraud and abuse.
Schemes to defraud the government are most common in areas of enterprise that receive the most federal funding. They can be broadly grouped in the following categories:
Qui Tam / Whistleblower Industries & Fraud Examples
Aerospace corporations that manufacture and maintain aircraft, spacecraft, and satellites under Department of Defense contracts can commit fraud by overbilling for parts and labor or supplying defective parts.
Defense Contractor Fraud
The U.S. government spends an estimated $553 billion per year on national defense. Defense contractor fraud commonly occurs when companies inflate the costs of goods or services, provide substandard equipment or services, improperly substitute products (such as used or refurbished) that are specifically called for in the contract terms, or improperly allocate costs in “cost-plus”contracts.
(Medicare and Medicaid)
Government healthcare programs are routinely targeted for fraud. Conservative estimates put the cost of healthcare fraud at around $68 billion on an annual basis. Healthcare fraud perpetrators use a seemingly endless variety of complex schemes to defraud Medicare, Medicaid and Tricare. Some of the most common schemes involve billing for health care services that were substandard, not medically necessary, or never actually provided, upcoding services to maximize reimbursements and paying kickbacks for patient referrals.
Hospice Care Fraud
Hospice care is meant for patients who have a life expectancy of six months or less. Some hospice care providers devise fraud schemes to bill Medicare for patients who are not terminally ill. Medical records may also be falsified to make it appear that patients either need hospice care or require the most expensive levels of care when patients are not eligible for either.
Mortgage fraud generally involves the omission, misrepresentation or misstatement of facts by banks or lending agents in securing mortgage loans, or the purchase or insuring of such loans. Common mortgage fraud schemes involve banks misrepresenting mortgages when applying for insurance under the Department of Housing and Urban Development’s Federal Housing Administration, issuing government-backed mortgages to borrowers that do not meet federal requirements, or packaging bad loans into mortgage-backed securities and misrepresenting their risk to investors.
Fraud in the pharmaceutical industry is widespread and may occur during the development, marketing, or sale of medications. Common pharmaceutical fraud schemes involve companies paying kickbacks to physicians or pharmacies to encourage the use of their drugs or promoting medications for uses that have not been approved by the Food and Drug Administration (FDA).
Securities fraud is one of the most devastating forms of fraud because its impact can affect not just individual investors, but the global economy, as was the case in the 2008 financial crisis. It is widely believed that the 2008 financial collapse was caused in part by various forms of securities fraud involving mortgage-backed securities. Ponzi schemes and insider trading are common securities fraud schemes.
Tax fraud by individuals and businesses has been estimated to cost the government over $450 billion annually. Tax fraud can be carried out by filing false or deceptive tax returns, hiding assets and income in offshore bank accounts, concealing business ownership or other financial activities, or through outright identify theft.