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4 Facts Physicians Should Know about the Medicare False Claims Act

Medicare False Claims Act

Medicare False Claims ActAs a physician who files claims through Medicare, there is pertinent information you need to know about the Medicare False Claims act. The False Claims Act allows for the prosecution of individuals who commit fraud against the United States government. Most physicians believe they are not at risk for committing Medicare fraud. However, it is crucial to understand the act in order to protect yourself from liability.

Are you a physician who files claims to Medicare for services you provide? There are 4 facts you should know about the Medicare False Claims Act:

#1. It is always illegal to misrepresent a service or product supplied to a patient in a Medicare claim.

In some cases, physicians believe they are acting out of benevolence, falsely diagnosing patients to allow them access to further coverage under Medicare. Whether or not the intention was to commit fraudulent activity in order to obtain government funds, it is never acceptable to misrepresent a service or product supplied in a Medicare claim.

#2. You may be liable for your employees’ actions.

If someone in your billing department or another employer bills for a service or product that wasn’t provided or upcodes a service, you may be liable for their actions. This is because you are the person receiving the fraudulently obtained government funds. Also, it is your responsibility to supervise the employees you hire.

#3. Accepting gifts or kickbacks of any kind is prosecutable under the False Claims Act.

If a vendor of any kind offers you incentive for your using their product, or attempts to use kickbacks to bias you towards their product, this is consider to be illegal under the False Claims Act. Never accept gifts of any kind of pharmaceutical companies or medical supplies.

#4. It is illegal to retaliate against whistleblowers.

Have you been found liable for fraudulent activity committed in your workplace? Then you can be further prosecuted if you retaliate against the person who reported your fraudulent actions. Therefore, it is crucial that you treat all of your employees fairly. Never terminate or punish someone engaging in whistleblowing activity.

In order to create an ethical workplace, you can encourage in-house whistleblowing among your employees. Reward employees for practicing transparency and honesty in the workplace. If an issue of any kind arises, do not try to conceal it. Instead, quickly report any fraudulent activity by the employees working for you in order to protect yourself from liability. An experienced whistleblower attorney can you protect yourself and your patients against complaints like this.

Have questions about the Medicare False Claims Act? Call the Bothwell Law Group at 770.643.1606.

The Top False Claims Act Penalties of 2015

false claims act penalties

false claims act penaltiesLast year was a record year for False Claims Act penalties, and 2015 is pacing similarly so far. As the year draws to a close, it has become clear how seriously the government is dealing with organizations and corporations who involve themselves in fraudulent activity. In fact, in 2015, we saw two of the largest settlements under the False Claims Act—each one right around $500 million.

In the first six months of the year, approximately $1.96 in government funds was recovered from the healthcare, government contracts, and financial industry.

The Top False Claims Act Penalties of 2015

Daiichi Sankyo Inc., $39 Million Settlement

This global pharmaceutical company agreed to a $39 million False Claims Act settlement after a whistleblower revealed they had been paying kickbacks to physicians who agreed in advance to prescribe the drugs they produce. A part of the False Claims Act is the Anti-Kick Back Statute, which aims to avoid physicians’ recommendations being biased because they have received gifts, monetary or otherwise.

The whistleblower in this case, Kathy Fragoules, received $6.1 million as a reward for filing a complaint against her former employer, Daiichi Sankyo Inc.

Community Health Systems Professional Services Corporation (CHSPSC), $75 Million Settlement

Along with three affiliated hospital in New Mexico, Community Health Systems Professional Services Corporation (CHSPSC), agreed to a $75 million settlement after they were accused of making illegal donations to local governments. These donations were then used as part of the state’s Medicaid payments to the hospitals.

The whistleblower in this case, Robert Baker, was the former CHSPSC revenue manager and he received $18,671,561 as a reward for filing a complaint against his former employer.

DaVita Healthcare Partners, $495 Million Settlement

This national kidney dialysis company announced in May that it would be paying a $495 million settlement as the result of a False Claims Act lawsuit. DaVita was accused of throwing away good medication after billing Medicare for it and are believed to fraudulently received millions of dollars of government funds as a result.

The whistleblowers in this case, Dr. Alon J. Vainer and Nurse Daniel D. Barbir, who were both employed by DaVita, will receive a combined total of $135 million as a reward for filing a complaint against their employer.

Trinity Industries, $663 Million Judgement

This government contractor was order to pay approximately $663 million after a judge deemed them liable for government funds lost as a result of the company’s actions. In the lawsuit against the company, it was revealed that Trinity has made changes to the guardrails they manufacturer without notifying federal regulators.

The whistleblower in this case was a former competitor of the company and they will receive an estimated $200 million dollars as a reward for filing a complaint against Trinity Industries.

If you have reason to believe you have information about fraudulent activity that may lead to False Claim Act penalties, contact a False Claims Act attorney by calling 770.643.1606.

What is a False Claim?

What is a false claim

What is a false claimIn essence, a false claim is any knowing claim or statement that is false and made for the purpose of defrauding another, or conspiring with another to do so. The False Claims Act (31 U.S. C. secs 3729-3733), or “Lincoln Law” is a federal statute that imposes liability on those who attempt to defraud governmental programs. These cases arise both in the pursuit of payment from governmental programs and the avoidance of payment rightfully owed to governmental programs.

What is a False Claim: Medicare and Medicaid

These claims arise in a surprisingly broad array of scenarios, many in the Medicare and Medicaid area, including fraudulent health care billing, performing inappropriate or unnecessary medical procedures, false billing of any kind for services not rendered or goods not delivered, misrepresentations regarding the quality of goods or services in billing, duplicate or false billing, or misrepresentations regarding actual costs in reimbursement claims. In all cases, in order to be held liable under the statute, the person must have submitted the false claim with knowledge of its falsity. This requirement includes: (1) actual knowledge, (2) deliberate ignorance of the truth or falsity of the information, or (3) reckless disregard of the truth or falsity of the information.

What is a False Claim: Anti-Kickback and the Stark Law

Kickbacks are also a violation of the False Claims Act. These kickbacks often involve either a hidden payment made in exchange for patient referrals, or another non-cash payment to a physician for patient referrals. These non-cash kickbacks often violate the Stark Law.

Physician self-referral is a practice in which an attorney refers a patient to a medical facility in which the physician or a member of the physician’s family has a financial interest. This poses the potential for a conflict of interest. The Stark Law is meant to prohibit this potential conflict from arising by prohibiting this self-referral. The Stark Law is a complex set of federal regulations. There are exceptions to the self-referral ban, but penalties for its violation are steep. Attorney assistance is required to determine if a violation has occurred or if the physician falls within one of the exceptions. Violation of the Stark Law is also a violation of the False Claims Act. The Stark Law (42 U.S.C. sec 1395 nn), or Physician Self-Referral Law.

Damages under the False Claims Act are substantial. For each false claim submitted, a penalty is assessed at between $5,500 and $11,000. Additionally, government’s actual damages are trebled. Damages calculations vary with the type of false claims made.

The False Claims Act allows private persons to file suit for its violation. This type of suit is called a “qui tam” action and the person bringing the suit is called a “relator.” These whistleblowers are an integral part of the False Claims Act and are rewarded and protected under the Act.