Avoiding False Claim Billing for your Practice

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Understanding False Claims Act

As a healthcare practice, you can typically submit claims to Medicare or Medicaid. Your claims are bills for goods you provide and services you conduct for patients. These federal health insurance programs cover the costs associated with your services. The False Claim Act is a federal law that makes it a crime for any person or organization to knowingly make a false record or file a false claim regarding any federal health care program, which includes any plan or program that provides health benefits, whether directly, through insurance or otherwise, which is funded directly, in whole or in part, by the United States Government or any state healthcare system. In other words, healthcare practices must not bill the government for things they did not do. Examples of false claims include billing for services not provided, billing for the same service more than once, or making false statements to obtain payment for services.

Penalties under the False Claims Act

Violations under the federal False Claims Act can result in significant fines and penalties. Financial penalties to the person or organization include recovery of three times the amount of the false claim(s), plus an additional penalty of $5,500.00 to $11,000.00 per claim. Violation of the MMFCA constitutes a felony punishable by imprisonment, a fine of $50,000 or less, or both, for each violation. A person who receives a benefit, because of fraud; makes a fraudulent statement; or knowingly conceals a material fact is liable to the state for a civil penalty equal to the full amount received plus triple damages.

Examples of False Claim Billing

Healthcare fraud can involve individuals or groups of healthcare workers misrepresenting their services and ending up overcharging the government. The United States Department of Justice listed a few instances of healthcare fraud.

• Billing for services not rendered or goods not provided: You cannot submit claims for medical services that you did not perform, treatments you did not offer, diagnostic tests you did not conduct, medical devices you did not use, or pharmaceuticals that you did not render. Regardless of the extra cost that you may earn from the false claims, you could get fines of up to three times the government’s loss.
• Falsifying certificates of medical necessity and billing for services not medically necessary: It is illegal to charge federal insurance companies for unnecessary medical services. Should the government discover that you billed them for performing a medical exam or prescribing medicine that the patient did not need, you could face charges for making a false claim.