Civil monetary penalties under the False Claims Act can include over $21,000 per false claim, treble (triple) damages, and recoupment of overbilled amounts. In criminal cases, providers can face potentially hundreds of thousands of dollars in fines, and up to five years of incarceration for each violation.
Full Answer
What are the fines for filing false Medicare claims?
Filing false claims may result in fines of up to three times the programs' loss plus $11,000 per claim filed. Under the civil FCA, each instance of an item or a service billed to Medicare or Medicaid counts as a claim, so fines can add up quickly.
Can a doctor be liable for false entries in Medicare claims?
a doctor who completes separate Medicare claims for each patient treated will be liable for a forfeiture for each such form that contains false entries even though several such forms may be submitted to the fiscal intermediary at one time. Id .
What is the civil money penalty for Medicare fraud?
The Civil Money Penalties Law (CMPL) authorizes the Secretary of Health and Human Services to impose civil money penalties, an assessment, and program exclusion for various forms of fraud and abuse involving the Medicare and Medicaid programs. Penalties range from $2,000 to $100,000 for each violati …
How much did the hospital pay for the False Claims Act?
The district court assessed 21,730 civil False Claims Act penalties. Ultimately, the hospital was on the hook for $119,515,000 in FCA penalties. United States ex rel Lutz v. BlueWave In United States ex rel Lutz v.
Who can impose CMPs?
The OIG may impose CMPs, assessments, and exclusions against individuals and entities that engage in fraud and other improper conduct related to HHS grants, contracts, and other agreements.
Who can seek a CMP exclusion?
The OIG may seek a CMP or exclusion against individuals or entities that present claims to Federal health care programs that the individual or entity knows or should know are for an item or service that was not provided as claimed or is false or fraudulent.
What is the anti kickback statute?
The Anti-Kickback Statute prohibits individuals or entities from asking for or receiving any remuneration in exchange for referrals of Federal health care program business. The OIG may seek a CMP or exclusion against individuals or entities who knowingly and willfully: (1) offer or pay remuneration, directly or indirectly, to induce referrals of Federal health care program business; or (2) solicit or receive remuneration, directly or indirectly, in return for referrals of Federal health care program business.
Can OIG seek CMP?
For example, the OIG may seek a CMP or exclusion against an individual or entity who makes claims for a service that is not actually provided, is provided but is already covered under another claim, is not properly coded, or is not supported by the medical record.
What are the penalties for false claims?
There also is a criminal FCA (18 U.S.C. § 287). Criminal penalties for submitting false claims include imprisonment and criminal fines. Physicians have gone to prison for submitting false health care claims. OIG also may impose administrative civil monetary penalties for false or fraudulent claims, as discussed below.
What are the laws that apply to physicians?
The five most important Federal fraud and abuse laws that apply to physicians are the False Claims Act (FCA), the Anti-Kickback Statute (AKS), the Physician Self-Referral Law (Stark law), the Exclusion Authorities, and the Civil Monetary Penalties Law (CMPL). Government agencies, including the Department of Justice, the Department of Health & Human Services Office of Inspector General (OIG), and the Centers for Medicare & Medicaid Services (CMS), are charged with enforcing these laws. As you begin your career, it is crucial to understand these laws not only because following them is the right thing to do, but also because violating them could result in criminal penalties, civil fines, exclusion from the Federal health care programs, or loss of your medical license from your State medical board.
What are the criminal offenses that OIG is required to exclude from?
OIG is legally required to exclude from participation in all Federal health care programs individuals and entities convicted of the following types of criminal offenses: (1) Medicare or Medicaid fraud , as well as any other offenses related to the delivery of items or services under Medicare or Medicaid; (2) patient abuse or neglect ; (3) felony convictions for other health-care-related fraud, theft, or other financial misconduct ; and (4) felony convictions for unlawful manufacture, distribution, prescription, or dispensing of controlled substances. OIG has discretion to exclude individuals and entities on several other grounds, including misdemeanor convictions related to health care fraud other than Medicare or Medicaid fraud or misdemeanor convictions in connection with the unlawful manufacture, distribution, prescription, or dispensing of controlled substances; suspension, revocation, or surrender of a license to provide health care for reasons bearing on professional competence, professional performance, or financial integrity; provision of unnecessary or substandard services; submission of false or fraudulent claims to a Federal health care program; engaging in unlawful kickback arrangements; and defaulting on health education loan or scholarship obligations.
What is the civil FCA?
The civil FCA protects the Government from being overcharged or sold shoddy goods or services. It is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent. Filing false claims may result in fines of up to three times the programs' loss plus $11,000 per claim filed. Under the civil FCA, each instance of an item or a service billed to Medicare or Medicaid counts as a claim, so fines can add up quickly. The fact that a claim results from a kickback or is made in violation of the Stark law also may render it false or fraudulent, creating liability under the civil FCA as well as the AKS or Stark law.
Why are physicians attractive to kickback schemes?
As a physician, you are an attractive target for kickback schemes because you can be a source of referrals for fellow physicians or other health care providers and suppliers. You decide what drugs your patients use, which specialists they see, and what health care services and supplies they receive.
What happens if you are excluded from Medicare?
If you are excluded by OIG from participation in the Federal health care programs, then Medicare, Medicaid, and other Federal health care programs, such as TRICARE and the Veterans Health Administration, will not pay for items or services that you furnish, order, or prescribe. Excluded physicians may not bill directly for treating Medicare and Medicaid patients, nor may their services be billed indirectly through an employer or a group practice. In addition, if you furnish services to a patient on a private-pay basis, no order or prescription that you give to that patient will be reimbursable by any Federal health care program.
What are the penalties for violating the AKS?
Criminal penalties and administrative sanctions for violating the AKS include fines, jail terms, and exclusion from participation in the Federal health care programs. Under the CMPL, physicians who pay or accept kickbacks also face penalties of up to $50,000 per kickback plus three times the amount of the remuneration.
What is the False Claims Act?
The False Claims Act, 31 U.S.C. §§ 3729, provides that anyone who violates the law is liable for a civil penalty in addition to three times the damages. False Claims Act penalties are sometimes referred to as statutory penalties or civil penalties or fines.
When was the False Claims Act amended?
In 1996, Congress amended that law to limit the initial increase to 10 percent of the maximum penalty. 110 Stat. 1321–373 (Apr. 26, 1996). In 1999, DOJ adjusted the False Claims Act penalties range for the first time. This amendment applied to violations occurring after September 29, 1999.
How Are The Precise Number and Amount Of FCA Penalties Decided?
Once you know the number of available False Claims Act statutory penalties and the applicable range, you can calculate a broad range of potential FCA penalties. But, the third step of the analysis is setting the exact number of False Claims Act penalties and penalty per violation. As we explain, in court, there is a role for both a jury and a judge. The jury determines the number of FCA penalties and the judge decided the False Claims Act penalty per violation. In a settlement, however, the government generally does not seek any penalties.
How many penalties are there for a false claim in Washington v. Morad?
There was no evidence on the number of violations, so, the Court imposed three FCA penalties per defendant. United States ex rel. Washington v. Morad, No. 15-868, 7 (E.D. La. Apr. 5, 2017). One civil penalty each for presenting or causing the presentment of false claims, 31 U.S.C. §§ 3729 (a) (1) (A), making or using false statements or records 31 U.S.C. §§ 3729 (a) (1) (B), and conspiring to violate the False Claims Act 31 U.S.C. §§ 3729 (a) (1) (C).
What are the penalties for false claims in 2020?
Reg. 37004 This adjustment included a catch up for 1999. 2020 False Claims Act penalties assessed after June 19, 2020 for post November 3, 2015 conduct, are $11,665 to $23,331.
How is the FCA penalty determined?
The FCA penalty is determined by counting each individual false claim or statement. United States v. Munoz-Escalante, 5:14-CV-05085-KES, 9-10 (D.S.D. Oct. 20, 2015) . This case involved hiring undocumented workers and using them on a federal Forest Services logging contract that required defendants to verify the workers’ eligibility, and pay prevailing wage and overtime. Defendants stiffed the workers and submitted invoices requesting payment in full. They also submitted false certifications stating that they had complied with the terms of the contract.
What is a false record?
False Records or Statements – Making, using, or causing others to make or use, a false record or statement that is material to a false or fraudulent claim. 31 U.S.C. §§ 3729 (a) (1) (B).
How to avoid civil penalties for Medicare fraud?
In order to avoid civil and criminal penalties for Medicare fraud, health care providers must intervene in the government’s investigation, assert their legal and Constitutional rights, and demonstrate to the federal investigators and prosecutors that the evidence does not support a federal prosecution. This requires experienced legal representation. At Oberheiden, P.C. we have decades of experience in Medicare fraud cases as both defense attorneys and senior federal healthcare prosecutors.
What is Medicare fraud?
In its most direct sense, Medicare fraud refers to collecting payment through the Medicare system when no payment is rightfully due. However, this can take many forms, and Medicare fraud investigations can involve allegations of a wide range of ancillary offenses as well. It is this breadth of prosecution that creates the greatest risk for legitimate healthcare providers, as even unintentional violations can potentially lead to substantial civil liability.
What are the penalties for false claims?
Civil monetary penalties under the False Claims Act can include over $21,000 per false claim, treble (triple) damages, and recoupment of overbilled amounts. In criminal cases, providers can face potentially hundreds of thousands of dollars in fines, and up to five years of incarceration for each violation. In both civil and criminal cases under the False Claims Act, providers can also face loss of hospital privileges, non-payment of future claims, program exclusion, and other penalties.
What are the penalties for Medicare fraud?
The penalties for Medicare fraud depend upon the specific allegations and federal laws involved in each particular case. In a civil case, the penalties are strictly financial in nature – although they can be far more substantial than most providers realize. In criminal cases, providers can face both fines and prison time – as well as various other significant consequences that can flow from a Medicare fraud conviction.
What charges can the DOJ charge for Medicare fraud?
For example, conspiracy charges are common, as are charges for money laundering, mail fraud, wire fraud , and other white-collar federal offenses.
How long is a healthcare fraud sentence?
If the fraud results in bodily injury, this is increased to 20 years. In cases involving death, healthcare providers (including physicians, pharmacists, executives, and other key personnel) can face life behind bars. A conviction under 18 U.S.C. 1347 can also result in substantial fines and loss of eligibility for Medicare and other healthcare benefit programs (also referred to as “program exclusion”).
What are Medicare billing and coding violations?
Medicare billing and coding violations, including up coding, unbundling, phantom billing, and billing for medically-unnecessary services or supplies
Drug Price Reporting
False and Fraudulent Claims
- The OIG may seek a CMP or exclusion against individuals or entities that present claims to Federal health care programs that the individual or entity knows or should know are for an item or service that was not provided as claimed or is false or fraudulent. For example, the OIG may seek a CMP or exclusion against an individual or entity who makes c...
Grants, Contracts, and Other Agreements
- The OIG may impose CMPs, assessments, and exclusions against individuals and entities that engage in fraud and other improper conduct related to HHS grants, contracts, and other agreements. The OIG may impose sanctions for, among other things, knowingly presenting a specified claim under a grant, contract, or other agreement that is false or fraudulent, or knowingly making or using any false statement, omission, or misreprese…
Kickback
- The Anti-Kickback Statute prohibits individuals or entities from asking for or receiving any remuneration in exchange for referrals of Federal health care program business. The OIG may seek a CMP or exclusion against individuals or entities who knowingly and willfully: (1) offer or pay remuneration, directly or indirectly, to induce referrals of Federal health care program business; or (2) solicit or receive remuneration, directly or indirectly, in r…
Misuse of Departmental Words and Emblems
- The Social Security Act prohibits an individual or entity's unauthorized use of words or emblems belonging to the Department of Health and Human Services (HHS). The OIG may seek a CMP against individuals or entities who without authorization use words or emblems belonging to the Department of Health and Human Services (HHS), or its programs, operating divisions or agencies, in connection with any communication in a manner which such …
Patient Dumping
- The Emergency Medical Treatment and Labor Act (EMTALA), also known as the patient dumping statute, is a federal law that requires anyone coming to an emergency department, with an emergency medical condition, to be stabilized and treated, regardless of their insurance status or ability to pay. If the hospital does not have the specialized capabilities required to stabilize the patient, the hospital must arrange for an appropriate transfer. Th…
Physician Self-Referral
- The Physician Self-Referral Statute, or Stark law as it is sometimes called, prohibits individuals or entities from referring Medicare or Medicaid patients for designated health services to entities with which individuals or entities have a direct or indirect financial relationship, unless an exception applies. The OIG may seek a CMP or exclusion against individuals or entities that present or cause to be presented a claim that the individual or entity knows or …
Select Agents and Toxins
- The Public Health Security and Bioterrorism Preparedness and Response Act of 2002 requires that entities and individuals who possess, use, or transfer select agents follow specific regulatory requirements. The OIG may seek a CMP against those who do not follow those regulatory requirements.