(October 23, 2019) - The Fake Claims Act (FCA) is designed to deter abuse and fraud of government benefits or contracts by private parties. Whenever a person or visitor contracts to provide services to the regime or regime beneficiaries, the FCA imposes liability on any contractor or business organisation that knowingly presents or causes to be presented a faux or fraudulent claim for payment or blessing, or that knowingly makes or uses a faux statement or tape to support a false or fraudulent merits. 31 USC § 3729(a)(ane).

When a healthcare provider contracts with the federal and state governments to treat Medicaid and Medicare patients for reimbursement, the healthcare provider's billing exercise is governed past the FCA and its country police counterparts. When a healthcare provider or the provider's practice submits claims to Medicaid or Medicare for reimbursement, the healthcare provider is liable for potential criminal and civil penalties to ensure that the billing submissions are true, accurate, and in compliance with the applicable service limits.

In evidently language, this means accurately and truly reporting the services performed for a patient on the engagement of service they were performed and ensuring that those services were really performed, properly performed (i.e. supported past medical necessity), and supported by documentation (i.east. medical records, diagnostic imaging studies, invoices for coldhearted or analgesic supplies, and practice calendars and day sheets).

Chiefly, a healthcare provider does non take to intentionally defraud the regime to be punished past the FCA. Instead, a healthcare provide tin be liable if the provider knew or should take known that the merits was false.

Examples of "should have known" liability include such situations as: (1) a healthcare provider completely ignorant of his billings practice, whether the ignorance was negligent or intentional; (2) a healthcare provider who notices inaccurate billing but fails to take activity to correct past and time to come claims (for case, if a provider notices his practise is billing more anesthesia time than is possible for his practice to really perform in a twenty-four hour period, but fails to arrange the billings practice or conform prior claims to reflect the time accurately); or (iii) a healthcare provider who observes consistent trends in billing submissions, such as up-coding or unbundling, but fails to take action.

Notably the absence of any type of compliance program may also be considered in determining whether a violation of the FCA has occurred.

Healthcare providers should as well know that they cannot insulate themselves from liability by hiring third parties to administer their billings practice. A healthcare provider does non actually have to submit the merits to be liable; instead, as the contracting party to provide services to government beneficiaries, a healthcare provider is liable for the submitted claim even if the claim is submitted past tertiary parties, such as staff or a billing contractor.

For each violation (i.e. a billing merits determined to exist false), a healthcare provider is subject to a $5,000 to $10,000 fine, and must pay dorsum all sums received equally a result of improperly submitted claims with an added multiplier which may be every bit much as three times the principle sum. Further, providers may be excluded from participation in Medicare and Medicaid or may be required to enter into a Corporate Integrity Agreement.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought near your specific circumstances.