Who pays when it comes to Medicare False Claims Act penalties? There are laws in place that require real penalties and pay rewards to citizens who report the fraud as well. The False Claims Act penalties exist to recover some of the billions of dollars fraudulently taken annually.

What Medicare False Claims Act Penalties Are There?

Unfortunately, Medicare is the pot of gold for several different types of fraudulent acts that carry strict penalties under the False Claims Act. There are blatant and continual scams being perpetrated. Under the Qui Tam Law, the person who brings these criminal acts to court can also be compensated if the government receives restitution from the case. Some of these include:

• Billing Medicare for services that were not provided
• Billing Medicare for services that were not medically necessary.
• Billing Medicare for services at a standard of care/certification that was not provided to the patient
• Kickbacks given for referrals of patients in Medicare
• Self-referral for Medicare patients

Medicare False Claims Act Penalties: How Does This Happen?

One of the largest types of crimes with penalties under the False Claims Act is billing Medicare for services that are never actually provided. Many times this is as simple as it sounds—submitting charges for services no one performs. Often, the deception is done so overtly that the patient files have nothing to back up the charge—no orders, no notation of the patient having been seen, or no follow up. When these cases are prosecuted, they are relatively easy to prove, although direct testimony from patients is needed.

Other fraudulent billing practices include coding issues. Each medical procedure has a code that someone enters into a form for billing purposes. Often an incorrect code is entered, leading to billing for a higher cost service. Human error accounts for some mistakes, of course, but a pattern of errors points to fraud.

Many services are bundled together and given a code as a group. Another type of coding error involves unbundling these services and placing individual charges, which can be significantly higher.

Another fraud consists of bills submitted to Medicare for services that are not medically necessary, such as unnecessary tests, imaging, or equipment.

Some providers will bill Medicare for services at a higher level of care than a patient received. This violation can include charging a specialist fee without the patient consulting with a specialist or charging for an M.D. when a nurse practitioner or physician’s assistant provided the services.

Kickbacks are a widely known type of fraud in the healthcare industry. Kickbacks concerning Medicare include providers who accept payment or reward in return for soliciting Medicare recipients. Many cases involve a health care provider receiving a financial incentive for purchasing special equipment and then billing Medicare for that equipment without revealing the kickback.

Self-referrals are when a doctor refers a patient to a practice in which the doctor is an invested owner. A doctor cannot be financially benefitting from a referral. A referral is done to get a client the best health care, not to increase one’s coffers.

So, Who Actually Pays for Medicare False Claims Act Penalties?

When a fraudulent claim is brought to court and successfully prosecuted, there are penalties to be paid. The penalties are based on the number of counts of fraud, the amount of money recovered, as well as up to three times the programs’ losses.

Every single charge, every single kickback, every single misrepresentation is considered a claim. It’s easy to see how the number of claims can add up quickly. The penalty for each claim is assessed on the amount of damages to the government—in other words, the amount of money Medicare paid out for the fraudulent claims. The liable party must pay three times the amount of these costs. Also, there is a penalty assessed between $5,500 and $11,000, for each claim.

The claim is paid by the person or business found liable for the fraud by the court. It should come as no surprise to anyone that there are insurance policies available to healthcare professionals to help defray these costs. Insurance can be obtained to cover both the defense and the penalties in False Claims Act claims.

If someone is notified of False Claims Act charges, they should immediately tender notice to their insurance provider. If the provider does not tender notice as soon as possible, they are potentially forfeiting their coverage and protection.

If you are looking for more information about False Claims Act penalties and how the Qui Tam Law benefits the person who brings this type of fraud to court, call (770) 643-1606 to learn more by contacting Bothwell Law Group online.