When compliance looks strong on paper but weak in practice, risk doesn’t just rise—it festers. In our latest Compliance Conversations, CJ Wolf talks with Jacklyn DeMar (President and CEO of The Anti-Fraud Coalition) and Elin Kunz (expert witness & former whistleblower) about the False Claims Act (FCA), retaliation, and how real programs prevent cases before they start.
The FCA lets insiders bring fraud concerns involving federal funds. Cases are filed under seal; the government may join or decline. Most matters settle—not because facts don’t matter, but because trials are long, costly, and risky. Specialized FCA counsel act as gatekeepers and won’t run with weak claims.
What whistleblowing really looks like.
Kunz describes a “choiceless choice”: years of internal reporting, persistent incentive problems, and preventable escalation. Her core advice: document meticulously (who/what/when/where), report up the chain, and verify remediation—don’t assume “closed” means “fixed.” If you must go outside, find experienced FCA counsel who know healthcare, Stark/AKS, and seal issues.
The FCA provides protections (e.g., double back pay) when employers act against protected activity. Strategy matters, especially if a retaliation claim runs alongside a sealed FCA case. Coordinate with counsel early.
Great policies fail without follow-through. Close three common gaps:
- Contracting + compliance: Put coding/compliance at the table for comp and physician contracts.
- Close the loop: Investigate, report outcomes back, and monitor to prove fixes stick.
- Resource audits on both sides: Facility and professional-fee expertise.
Resources from The Anti-Fraud Coalition
Healthicity
Questions or Comments?