False Claims Act (FCA) [Healthcare Compliance Tips]

Research the False Claims Act (FCA) and share with your staff how it applies to your practice (with examples).

In the next few posts, we will discuss the federal laws governing Medicare and some commercial insurances.

The first law on our list is the False Claims Act (FCA).

What is the False Claims Act?

This Act imposes civil liability on any person who knowingly submits or causes the submission of, a false or fraudulent claim to the Federal government.

What do the terms “knowing” and “knowingly” mean?

Per CMS, the terms “knowing” and “knowingly” mean a person has actual knowledge of the information or acts in deliberate ignorance or reckless disregard of the truth or falsity of the information related to the claim. No specific intent to defraud is required to violate the civil FCA.

What are some examples?

• A physician knowingly submits claims to Medicare for medical services not provided or for a higher level of medical services than actually provided.
• Falsifying diagnosis codes.
• Filing duplicate claims for the same procedure.
• Billing for unnecessary procedures.

What are the penalties?

• Recovery up to three times the amount of damages, plus penalties up to $22,927 per false claim filed (as of 2019).
• Individuals or entities may face criminal charges, which includes imprisonment.

Conclusion

Remember, the government knows the difference between “erroneous” and “fraudulent” claims.  And, that most physicians are ethical and provide high- quality care and proper claim submission.

However, still, use the information provided in this tip as a conversation piece to educate your staff on the importance of following the False Claims Act (FCA).

Never assume they understand the law.  The more you explain your expectations, the more they will take their job seriously and protect patient claims.

**The opinions and observations from the group/author are not a promise to exempt your practice from fines and penalties.  Research, modify, and tailor the advice to fit your specialty.