The False Claims Act, Physician Self-Referral Law, and Exclusion Statute are included as the main Federal fraud and abuse laws applicable to physicians. It is important to understand and follow these laws, because failure to do so can result in punishments ranging from civil fines to exclusion from Federal healthcare programs.
Defining Fraud, Waste and Abuse
Fraud is knowingly submitting false claims in order to receive a Federal health care payment. Without these actions, access to these payments would not be available. Waste is overusing resources and not consciously thinking about expenses. This negatively effects the healthcare benefit program as they are spending excess money. Lastly, abuse describes actions that cause unnecessary costs to the Medicare Program.
False Claims Act
This act states that it is illegal to knowingly submit false claims for payment to Medicare or Medicaid. “Knowing” means that the person either has knowledge on the information or disregards the truth of the claim due to ignorance. So, punishments include fines up to three times the programs’ loss. In addition, the False Claims Act includes a whistleblower provision. Through this, private individuals are able to file a lawsuit on behalf of the United States and receive a percentage of any recoveries. Lastly, there is a criminal False Claims Act which may include punishments such as imprisonment and criminal fines.
Physician Self-Referral Law
Another law includes the Physician Self-Referral Law, also known as the Stark Law. This states that physicians are not able to refer patients to designated healthcare services payable by Medicare or Medicaid from entities the physician or family member has a financial relationship with. A financial relationship can be any ownership or investment interests and compensation arrangements. Also, healthcare services can include clinical laboratory, physical therapy and radiation therapy services. This is a strict liability statute. Therefore, proof of violation of law is not necessary. A violation results in a fine and exclusion from participation in Federal healthcare programs.
Exclusion Statute
The Exclusion Statute requires the Office of Inspector General (OIG) to remove any individual or entities from the Federal healthcare programs that has been convicted of a criminal offense. These offenses can include Medicare or Medicaid fraud, patient abuse or neglect, felony conviction for other healthcare misconduct, or felony conviction for unlawful use of controlled substances. If excluded from the Federal healthcare programs, then the programs will not pay for any services or items requested. As a healthcare employee, a main responsibility is to not employ or contract any excluded individuals or entities. In order to do this, it is necessary to screen all current and prospective employees and contractors.
Get Certified
Fraud, waste and abuse is important for providers to understand in order to keep it from happening in the workplace. American Medical Compliance (AMC) is a leader in the industry for compliance, Billing and HR solutions. To become certified, please visit us at: www.americanmedicalcompliance.com.
Reference:
Medicare fraud & abuse: Prevent, DETECT, REPORT. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud-Abuse-MLN4649244.pdf
Fraud & abuse laws. Office of Inspector General | Government Oversight | U.S. Department of Health and Human Services. (2021, September 2). https://oig.hhs.gov/compliance/physician-education/fraud-abuse-laws/
