See real healthcare fraud examples under the False Claims Act, including billing scams, kickbacks, forged records, and improper reimbursements. Review penalties, whistleblower protections, and how Medicare and Medicaid fraud cases lead to fines, settlements, and criminal charges.
By Brad Nakase, Attorney
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The False Claims Act prohibits healthcare professionals from filing false claims. This basically means that doctors’ offices are not allowed to charge the government for services or products that they did not provide.
A medical practice can often file claims to Medicaid or Medicare. These claims are invoices for products and services rendered to patients. These products and services are covered by federal health insurance programs (Medicare & Medicaid).
The FCA was passed in 1863. During the US Civil War, defense contractor fraud prompted its introduction. Contractors would offer the Union Army faulty products during the conflict. Sickly mules and horses, malfunctioning guns, and spoiled food. Congress enacted the federal law in reaction to this.
This law still holds people accountable for defrauding government programs today. Any individual or group that willfully does so faces a fine that is closely correlated with inflation, in addition to three times the amount of government damages.
The demand for assets or cash based on serious deception or a lie is known as a false claim. There can be other False Claims Act Healthcare Examples.
Under the FCA, an individual or business may be held accountable if they:
The Anti-Kickback Statute (AKS) forbids physicians from taking gifts & other rewards in exchange for prescription orders/referrals. Together, they fight abuse and fraud in health insurance programs for services that are not medically essential.
Offering, paying, requesting, or getting anything good in exchange for referrals is forbidden under the AKS. The federal government will eventually pay for these patient referrals. The False Claims Act is violated when a physician makes a false claim that was influenced by a kickback.
Any allegation of kickbacks is considered a false claim according to the Protection & Affordable Care Act.
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Similarly, doctors who refer patients to themselves may be subject to FCA responsibility. Referrals to organizations with which a practitioner has a financial relationship are prohibited by the Physician Self-Referral Law (Stark Law). According to this law, the referring physician cannot profit from these Medicare or Medicaid-payable medical services.
Whistleblowers are the first to identify false or misleading claims. They are the individuals who present evidence of wrongdoing. This could be a manager, an employee, or even a third party. They have the right to sue according to the civil False Claims Act if they witness the misappropriation of public monies. These are cases of qui tam.
Those who discover fraud are rewarded and encouraged by the False Claims Act’s qui tam clause. It is strongly encouraged to uncover instances of misconduct and programs for medically unnecessary care. Those who sound the alarm are protected from reprisals by the whistleblower statute. Additionally, it provides financial benefits in the event that the lawsuit results in reported verdicts and settlements.
Your business must give compliance first priority if you want to avoid breaking the False Claims Act. It’s essential to educate & be open with your team. Realize that the False Claims Act additionally encompasses a variety of federal programs, regardless of the industry you work in.
False claims and improper billing procedures may result in civil fines, criminal charges, or both. This is even when they’re inadvertent. Prison time is one of the penalties, along with millions in judgments and settlements under the Claims Act.
An excellent place to start is with a compliance officer who is committed to implementing the False Claims Act structure inside your company. Employee training, audits, and ongoing verification of appropriate billing procedures are all important.
Healthcare fraud can be committed by individuals or teams of healthcare professionals. They overcharge the government and misrepresent their services. The United States Department of Justice lists a few False Claims Act Healthcare examples that people should be mindful of.
It is not possible for a healthcare professional to file a reimbursement for a medical treatment they did not provide. Additionally, tests that weren’t carried out, devices that weren’t utilized, and medications that weren’t prescribed cannot be claimed. These incorrect claims can result in fines that are as much as three times the loss of the government program.
John, for instance, is covered by Medicaid. He receives just one diagnostic test when he visits his physician for an infection. However, the physician claims in a Medicaid claim that John additionally underwent further diagnostic procedures that were never really performed. The doctor is penalized under the FCA for each test that is not performed.
Medical professionals are prohibited by law from billing federal insurance providers for needless medical procedures. A doctor may be charged with fraudulent claims if they bill the government after completing an examination or writing a prescription for medication that the patient did not require.
It is one of the prominent False Claims Act Healthcare Examples.
A healthcare professional could be charged with serious crimes if they fabricate documents to support misleading claims. These accusations would be covered by the FCA’s criminal section.
For instance, Dr. Adams fabricates a medical record for Susie, a patient, stating that she suffers from severe psoriasis. He performs needless operations and prescribes needless steroids using this fictitious record. Susie seeks a second opinion from a different physician. The physician finds that Doctor Adams has faked her health information & treatment plan. Susie has only mild psoriasis. Doctor Adams is thus charged with a crime.
This fraud technique is comparable to charging the government for services or products that were not rendered. But in this case, a physician is lying about their eligibility for reimbursement.
According to federal law, doctors who refer patients to health programs (federal) are not permitted to get “kickbacks.” Kickbacks might involve cash or any other valuable object. A physician advocating that one of the patients they treat visit an entity that bills Medicaid is an example of this. The doctor is compensated by this practice for recommending the patient. This conduct is prohibited, as is healthcare fraud.
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