Understanding Laws Against Medicare Fraud And Abuse

Virginia residents will understand the seriousness of crimes related to fraud or abuse against the government program of Medicare. However, there are different laws that dictate what constitutes this type of fraud. It is important to understand the federal laws for fraud and abuse of Medicare. The following are laws that can be violated in this way: Federal False Claims Act or FCA, Anti-Kickback Statute or AKS and Physician Self-Referral Law or Stark Law.

With FCA, the goal is for the federal government to be protected from overcharge. If there is a knowing submission of a false or fraudulent claim to the federal government, there can be charges under FCA. If this is done knowingly, it means that the person had knowledge that the information or acts disregarded the truth when submitting the claim. There does not need to be intent shown for there to be a violation of FCA. A doctor submitting a claim for a higher level of services than what was provided is an example. The penalties can include a fine of as much as three times the amount of damage the government suffered per claim. With the criminal FCA statute, individuals and entities can be fined, imprisoned or both.

AKS is when there is a reward offered, paid, solicited or received for items or services that will be reimbursed by the federal government. An example might be cash exchanged for office space at less than market value for referrals. Currently, there can be penalties of $73,588 for every kickback and three times the amount of the kickback itself. With criminal charges, there can be fines, jail or both. The Physician Self-Referral Law – also known as the Stark Law – is meant to keep a physician from referring a patient to receive health services from the physician or a family member of the physician who owns or has a stake in an entity. Currently, penalties for violating this law can be fines of up to $23,863 for every service, claim repayments and possible exclusion from the federal programs.

Since massive structures like Medicaid might seem overwhelmed, people might make the mistake of issuing inaccurate information and violate the above statutes. Or it might have been an honest mistake in which the person got caught up and arrested. Regardless, when there are allegations related to Medicare fraud, the penalties can be significant and lead to long-term problems. Because of that, the first call that should be made when part of an investigation or placed under arrest for these charges is to a legal professional experienced in Medicare cases.

Source: cms.gov, “Medicare Fraud & Abuse: Prevention Detection, and Reporting — pages 5-7,” accessed on Dec. 18, 2016