False Claims Act
As with other laws in the healthcare industry, the False Claims Act has numerous nuances of which licensed healthcare professionals must be aware. But keeping up with all the nuances of all the industry rules and regulations can seem impossible. That’s where the experienced legal team at Norman Spencer Law Group can help.
Our healthcare attorneys are well-versed in industry rules and regulations, including the False Claims Act. Not only do we handle all matters related to false claims allegations, but we can also review your procedures and policies to ensure you are not at risk for breaking the law.
What is the False Claims Act?
The False Claims Act is a federal law that makes it unlawful for anyone to present, conspire to present, or receive funds from a fraudulent claim for a government payment. False claims submitted to Medicare and the Centers of Medicare & Medicaid Services (CMS) are two of the most common government programs often associated with the False Claims Act.
While the law may appear rather straightforward, it does have a very important exception. Licensed healthcare professionals are not liable for submitting a false claim under the False Claims Act if they were not aware that the claim was false. Knowledge of the claim’s falsity can be defined as:
- Actually knowing the claim was false
- Deliberately keeping themselves unaware of the truth or falsity of the claim
- Recklessly disregarding the truth or falsity of the claim
The false claim lawyers at Norman Spencer Law Group are extensively experienced in handling false claim matters at both the criminal and civil levels. We’re also able to help you analyze your business procedures and policies to make sure you consistently avoid civil and criminal liabilities associated with violations of the False Claims Act.
Many states have followed the federal government’s lead and have false claims acts of their own.
Types of False Claim Violations
A number of different activities can subject healthcare professionals to penalties, fines and criminal prosecution under both federal and state false claims acts. While the acts may have exemptions in certain cases, they are also riddled with pitfalls into which healthcare providers can inadvertently find themselves. Potential violations of false claims acts include:
- Services not rendered: Billing for services not provided or performed on a patient.
- Lack of medical necessity: Performing additional tests or treatments that are not medically necessary for the sole purpose of increasing the bill.
- Ghost patients: Submitting claims for tests, medical devices or services for a patient that doesn’t exist, or with which the healthcare provider has no doctor-patient relationship.
- Unbundling: Billing individually for treatments or tests that are part of a group that is billed as a unit; this is often done to increase the overall price of the treatment.
- Up-coding services: Assigning a higher code for a treatment in order to increase billing.
- Kickbacks: Receiving remuneration in exchange for referring patients to Medicare, Medicaid or other healthcare service payable by the government.
- Stark and anti-kickback: Making referrals to an entity or individual with which the physician has a financial interest.
- Insufficient physician supervision: Undertaking procedures without the required supervision as outlined in the conditions of participation for TRICARE, Medicaid and the Federal Employees Health Benefit Program.
- Using excluded providers: Submitting claims on behalf of providers not eligible to bill Medicaid and Medicare. The online HHS database lists excluded individuals and entities.
- Research grant fraud: Falsifying research results and data, or submitting a false grant application to secure a grant. This also includes using grant money for purposes other than the one for which it was provided.
- Accepting gifts or money from a device or drug company
- Duplicate billing
It’s extremely important for healthcare professionals to be meticulous in their billing practices, ensuring they align with federal guidelines. A procedural issue or billing error could otherwise result in severe fines and even criminal penalties. Seeking assistance from an experienced healthcare attorney can ensure your practices are consistent with state and federal regulations.
False Claims Act Penalties
Penalties for violating the federal False Claims Act doubled in 2016, increasing the monetary penalty to more than $21,500. Those found in violation of the False Claims Act must also pay triple the amount of the government’s damages, along with reimbursement of lawyer costs and fees. Because false claim violations are felonies, they are punishable by up to five years in prison – per claim.
Healthcare professionals can face both criminal and civil penalties for a violation. The civil penalties also doubled, increasing from $250,000 to $500,000.
The best way to protect your practice, reputation and career is to take preventative action to ensure you’re not at risk of violating federal and state false claims acts. The attorneys at Norman Spencer Law Group are at your service. Call to schedule a consultation today.