Q: Medicare FCA/FOIA exception criteria.

A: In Medicare False Claims Act (FCA) cases, the government's approach to balancing hospital or hospice privacy rights with a relator's right to justice is guided by both the FCA and the Freedom of Information Act (FOIA). The FCA provides mechanisms for whistleblowers to report fraud, while FOIA regulates the disclosure of government information, including investigations into healthcare fraud.

The Office of Inspector General (OIG) and the Centers for Medicare & Medicaid Services (CMS) typically handle these investigations. They must balance confidentiality and privacy concerns with the need for transparency and accountability. In cases where the FCA amount in question is relatively small, the government may choose not to intervene. However, this decision can depend on various factors, including the potential for a pattern of fraud to be uncovered.

If the government decides not to intervene, the relator may still proceed with the case independently. Regarding the disclosure of investigation findings, generally, these findings are not shared directly with relators while the case is under seal. However, once the case is unsealed, information may become more accessible, subject to privacy and confidentiality laws.

It's advisable for anyone involved in such a case to seek legal guidance to navigate these complexities. An experienced attorney can provide specific advice on how these laws may apply in your particular situation and what steps can be taken to address your concerns.