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False Claims Act

Pursuant to Section 1902(a) (68) of the Social Security Act, Wayne RESA, as the Medicaid Provider for School Based Services for 33 districts in Wayne County, is required to comply with Section 6032 of the Deficit Reduction Act (DRA) of 2005. Wayne RESA is subject to this act because we receive or make at least $5 million in annual aggregate payments from the federal Medicaid program.

A section of the law entitled "Employee Education About False Claims" cites three (3) requirements; 1) Establish written policies for employees and contractors about the False Claims Act; 2) Establish detailed provision in these policies for detecting fraud, waste and abuse, as well as administrative remedies for false claims; 3) Inform all providers about these policies and their rights to be protected as whistleblowers.

The Federal False Claims Act, among other things, applies to the submission of claims by healthcare providers for payment by Medicare, Medicaid and other federal and state healthcare programs. The False Claims Act is the federal government's primary civil remedy for improper or fraudulent claims. It applies to all federal programs, from military procurement contracts to welfare benefits to healthcare benefits.

The False Claims Act prohibits among other things:

  • Knowingly presenting or causing to be presented to the federal government a false or fraudulent claim for payment or approval;
  • Knowingly making or using, or causing to be made or used a false record or statement in order to have a false or fraudulent claim paid or approved by the government.
  • Conspiring to defraud the government by getting a false or fraudulent claim allowed or paid; and
  • Knowingly making or using, or causing to made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the government.

Any person who knowingly attempts to defraud the federal government is liable to the United State Government for a civil penalty of not less than $5,000 and not more than $10,000, plus 3 times the amount of damages which the Government sustains because of the act of that person.

"Knowingly" means that a person, with respect to information: 1) has actual knowledge of the information; 2) acts in deliberate ignorance of the truth or falsity of the information; or 3) acts in reckless disregard of the truth or falsity of the information.


The United States Attorney General may bring civil actions for violations of the False Claims Act. As with most other civil actions, the government must establish its case by presenting a preponderance of the evidence rather than meeting the higher burden of proof that applies in criminal cases. The False Claims Act allows private individuals to bring "qui tam" actions for violations of the False Claims Act.

Protection for "Whistleblowers":

Federal and state law 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.

To report Medicaid provider fraud:

Call the Attorney General's 24-hour Hotline at 800-24-ABUSE (800-242-2873);
e-mail or visit the Attorney General's web site.

For further information read the Wayne RESA Board Policy GF False Claims Act (PDF) and the Medicaid Quality Assurance Plan (PDF).