What Every Healthcare Provider Should Know About The False Claims Act
The False Claims Act (FCA) is a law designed to protect government healthcare programs, like Medicare and Medicaid, from being overcharged or misled. If healthcare providers submit claims they know—or should know—are false, they could face serious penalties, including hefty fines. Each false claim submitted can result in fines of up to three times the government’s loss, plus an additional $11,000 per claim.
Even if a healthcare provider doesn’t intend to commit fraud, they can still be held responsible under the FCA if they acted with reckless disregard for whether their claims were accurate. For example, if a physician submits incorrect billing information due to negligence or fails to verify the accuracy of claims, they can be liable.
How Healthcare Providers Can End Up Violating the FCA
There are several ways doctors and healthcare providers might unintentionally violate the FCA:
- Submitting False Claims: This occurs when a provider bills Medicare or Medicaid for services they didn’t actually provide or inflates the cost of services rendered.
- Kickbacks: If a doctor receives money or gifts in exchange for referring patients to specific services, like diagnostic tests or medications, it could be considered a kickback, which makes any associated claims to Medicare fraudulent.
- Violations of the Stark Law: If a doctor refers patients to entities they own or have a financial interest in, this is considered a conflict of interest under the Stark Law, and any related claims could be considered false under the FCA.
No Intent to Defraud? You Could Still Be Liable
One of the most challenging aspects of the FCA is that a doctor doesn’t need to have intended to commit fraud. The law considers “knowing” to include cases of deliberate ignorance or reckless disregard for the truth. This means that failing to double-check claims before submitting them could lead to legal trouble, even if the mistake wasn’t intentional.
For example, if a billing department accidentally upcodes (bills for a more expensive service than what was provided) or submits duplicate claims and the physician doesn’t catch the error, they could still be held liable.
Whistleblowers and the FCA
The FCA has a special provision that allows whistleblowers—often employees, former partners, or even patients—to report fraud. These individuals can file lawsuits on behalf of the government if they have evidence that a healthcare provider is defrauding Medicare or Medicaid. If the lawsuit is successful, the whistleblower may receive a portion of the money recovered, which can incentivize people to come forward.
This makes it even more critical for doctors to ensure that their billing practices are airtight. A disgruntled employee could expose potential vulnerabilities in billing procedures, leading to a costly investigation.
What Are the Penalties for Violating the FCA?
Violating the FCA can result in significant financial penalties. Each false claim submitted to Medicare or Medicaid can result in a fine of up to three times the government’s loss, plus an additional $11,000 per claim. Given the number of claims a medical office submits, these fines can add up quickly.
For instance, if a doctor’s office submits hundreds of claims over time that include false or inflated charges, the penalties could easily reach millions of dollars. In some cases, providers might also face criminal charges, which could result in prison time.
Defense Strategies for False Claim Allegations
If a healthcare provider faces FCA allegations, it’s crucial to consult with a Florida false and fraudulent claims lawyer to protect their practice and reputation. Here are a few common defense strategies:
- Lack of Knowledge: A provider might argue that they did not knowingly submit false claims. If errors occurred due to a misunderstanding of complex billing rules, this could reduce liability.
- Good Faith Compliance: Demonstrating that the provider took reasonable steps to comply with Medicare and Medicaid rules can be a strong defense. This could involve having an effective compliance program in place and conducting regular audits.
- Challenging the Evidence: In many FCA cases, the government’s evidence may be weak or incomplete. A skilled defense lawyer can challenge the claims and show that the errors were not intentional.
- Negotiating Settlements: In some cases, healthcare providers may choose to negotiate with the government to reduce penalties. By cooperating with the investigation and offering to repay any improperly received funds, providers can often avoid the harshest outcomes.
Contact The Baez Law Firm
The False Claims Act is a powerful tool that the government uses to protect itself from healthcare fraud. For doctors and healthcare providers, it’s critical to understand the complexities of the FCA and ensure compliance with Medicare and Medicaid regulations. Even unintentional mistakes can lead to significant penalties, making it essential to have proper systems in place to avoid errors. If faced with FCA allegations, seeking legal guidance quickly is crucial to mitigate potential penalties.
If you are a healthcare provider facing allegations of submitting false claims, The Baez Law Firm is here to help. Our experienced attorneys can provide the legal representation you need to protect your practice and your reputation. Contact us today for a consultation.
Sources:
justice.gov/civil/false-claims-act#:~:text=Many%20of%20the%20Fraud%20Section’s,during%20the%20American%20Civil%20War.
uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title31-section3729&num=0&edition=prelim
