What do you need to know about Medicare fraud?
Federal laws governing Medicare fraud and abuse include the: False Claims Act (FCA) Anti-Kickback Statute (AKS) Physician Self-Referral Law (Stark Law) Social Security Act, which includes the Exclusion Statute and the Civil Monetary …
What are the potential penalties for Medicare fraud?
Dec 01, 2021 · Current Law and Regulations. Section 1877 of the Social Security Act (42 U.S.C. 1395nn) prohibits physicians from referring Medicare patients for certain designated health services (DHS) to an entity with which the physician or a member of the physician's immediate family has a financial relationship unless an exception applies. It also prohibits an entity from …
What is considered Medicare fraud?
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 …
How to protect yourself against Medicare fraud?
Sep 14, 2015 · 5 Laws Governing Medicare Fraud: United States Criminal Code; Anti-Kickback Statue (AKS) False Claims Act (FCA) Physician Self-Referral Law (Stark Law) Social Security Act; 5 Conditions That Must Be Met according to Medicare.gov: You report your suspected Medicare fraud. The allegation must be specific, not general.
What is considered Medicare Fraud?
Knowingly submitting false statements or misrepresenting facts to get federal health care payment when an entitlement would not exist otherwise;
5 Conditions That Must Be Met according to Medicare.gov
You report your suspected Medicare fraud. The allegation must be specific, not general.
Example
For example, you didn’t participate in the fraud offense being reported. Or, there isn’t another reward that you qualify for under another government program.
What is the AKS law?
Anti-Kickback Statute (AKS) Physician Self-Referral Law (Stark Law) Social Security Act, which includes the Exclusion Statute and the Civil Monetary Penalties Law (CMPL) Below are details of each of these important healthcare fraud laws.
Can a doctor refer a patient to Medicare?
This healthcare fraud law bars a doctor from referring patients to receive certain healthcare services that are payable to Medicaid or Medicare to a healthcare entity with which the doctor or his immediate family has a financial relationship.
What is the criminal law for healthcare fraud?
This law bans knowingly and willfully executing a scheme in connection with the delivery of or payment for healthcare benefits, items, services to defraud any healthcare benefit program, or obtain any money or property owned by or under the control of any US healthcare benefit program.
What is CMPL in healthcare?
Civil Monetary Penalties Law (CMPL) This law allows the Office of the Inspector General to seek civil monetary penalties (CMPs) and/or exclusion from Medicare and Medicaid participation for several types of healthcare fraud. Penalties and assessments vary based on the violation type.
What is healthcare fraud?
Healthcare fraud typically involves any of the following crimes: Knowingly submitting false claims or making misrepresentations of fact to obtain a Medicare or Medicaid payment to which the person is not entitled.
How long does it take to get an indictment for health care fraud?
Under federal statute 18 USC 3282, people who commit health care fraud are protected from prosecution for any noncapital offense in which an indictment is not found within five years of the criminal act.
Is Medicare fraud illegal?
Defrauding the US government through healthcare fraud is illegal. Committing Medicare and Medicaid fraud exposes individuals and health care organizations to possible criminal, civil, and administrative penalties. Some healthcare fraud criminals face years in prison and thousands of dollars in fines.
What are the laws that regulate referrals?
These laws are intended to prevent conflicts of interest between provider financial incentives and best patient care practices. Federal "fraud and abuse" law is actually a compilation of several laws, including the Federal Anti-Kickback Statute, the Stark Law, and the False Claims Act.
Who is a whistleblower under the False Claims Act?
Under the False Claims Act's qui tam provisions, a person with evidence of fraud against the government (known as a "relator" or a "whistle-blower") is authorized to file a case in federal court and sue on behalf of the government.
Is Medicare a federal program?
The Medicare, Medicaid, and TRICARE Programs are all Federal Healthcare Programs. Certain transactions and arrangements are statutorily exempt from the Federal Anti-Kickback Statute (e.g., compensation paid pursuant to a bona fide employment relationship).
What is fraud and abuse law?
Federal "fraud and abuse" law is actually a compilation of several laws, including the Federal Anti-Kickback Statute, the Stark Law, and the False Claims Act. A. The Federal Anti-Kickback Statute. The Federal Anti-Kickback Statute (42 U.S.C. § 1320a-7 (b)) prohibits providers of services or goods covered by a federal healthcare program ...
Is Safe Harbor illegal?
Significantly, however, a transaction or arrangement that does not meet all the requirements of a Safe Harbor regulation is not per se illegal. The Federal Anti-Kickback Statute is a criminal statute and the penalties for violations of the law can be severe.
What is federal health care?
For purposes of the Federal Anti-Kickback Statute, a "Federal Healthcare Program" is defined as "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 health care program . . .". (42 U.S.C. § 1320a-7 (b) (f)). ...
Is the Stark Law a strict liability statute?
Unlike the Anti-Kickback Statute, the Stark Law is a strict liability statute and thus, no proof of bad intent is required to violate the Stark law. As a result, any arrangement that does not satisfy all of the criteria of a statutorily-defined Stark Law exception is illegal.
What are the laws governing Medicare Part C and D?
Some of the laws governing Medicare Parts C and D Fraud, Waste, and Abuse ( FWA) include the Health Insurance Portability and Accountability Act (HIPAA); the False Claims Act; the Anti- Kickback Statute; the List of Excluded Individuals and Entities (LEIE); and the Health Care Fraud Statute.
Who is responsible for compliance?
Compliance is the responsibility of the Compliance Officer, Compliance Committee, and Upper Management only.
What is FWA in Medicare?
Ways to report potential Fraud, Waste, and Abuse (FWA) include Waste includes any misuse of resources such as the overuse of services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare Program.
Healthcare Fraud Laws
- There are several federal laws in place to combat healthcare fraud. They are: 1. False Claims Act (FCA) 2. Anti-Kickback Statute (AKS) 3. Physician Self-Referral Law (Stark Law) 4. Social Security Act, which includes the Exclusion Statute and the Civil Monetary Penalties Law (CMPL) Below are details of each of these important healthcare fraud laws....
Healthcare Fraud Punishment
- Healthcare fraud punishments depend on the severity of the crime and which healthcare fraud law you violated: 1. Federal False Claims Act: Civil penalties for violating the FCA can be the recovery of as much as three times the amount of damages the US government sustains because of the false claims. There also can be a penalty of up to $22,927 per false claim. 2. Anti-Kickback Statu…
Sentencing Guidelines
- The United States Sentencing Commission has guidelines that establish the prison time that violators can receive for committing healthcare fraud. According to 2018 USSC statistics, the average sentence for healthcare fraud is 30 months, and 73.4% of offenders received a prison sentence. Approximately 55.5% of healthcare fraud offenders were sentenced according to the …
Statute of Limitations
- Under federal statute 18 USC 3282, people who commit health care fraud are protected from prosecution for any noncapital offense in which an indictment is not found within five years of the criminal act. References 1. Medicare and Medicaid Fraud. Accessed at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/…