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Navigating the Waters of the False Claims Act (FCA)

| September 25, 2018

Navigating the Waters of the False Claims Act (FCA)

Knowledge, adaptability and longevity are a few core values of Med USA. To mitigate risk and help our clients continue to prosper we provide services and software solutions to help reduce the administrative burdens that continually mount upon practices of all sizes.  

In 2013, Olympus Corp. paid $310.8 million to settle a civil FCA case. What is FCA? The False Claims Act (FCA) prohibits anyone from knowingly submitting a false claim for payment to the federal government. The FCA covers every claim for Medicare reimbursement, so every physician’s practice group should understand what it is and how it works.

In this post, we’ll cover the kinds of conduct the FCA prohibits, the penalties that can be imposed for violating it and the unique procedure for bringing a claim under it.

What the FCA Prohibits

The FCA prohibits several broad categories of conduct:

  • Knowingly presenting a false or fraudulent claim for payment to the federal government;
  • Knowingly “causing to be presented” a false or fraudulent claim;
  • Knowingly using (or causing to be used) a false statement or false record to get the federal government to pay a claim;
  • Conspiracy with other individuals or entities to get the federal government to pay a false claim;
  • Knowingly using (or causing to be used) a false statement or false record to avoid paying all or part of a financial obligation to the federal government.
  • To take a simple example, if a practice group submits a Medicare claim for reimbursement for the examination of a patient that never took place, then this is a false claim. But FCA liability can arise in all sorts of contexts, including:
  • Upcoding procedures
  • Unbundling procedures
  • Filing multiple claims for the same procedure
  • Billing for medically unnecessary procedures
  • Violating the Anti-Kickback Statute

Penalties Under the FCA

The FCA’s broad reach is coupled with serious penalties. Perhaps most significant is that the government can recover treble—or triple—damages for violations. So, if you submit $100,000 in false claims to the government, the possible liability is $300,000.

In addition, a court must impose civil penalties for each false claim submitted. In June 2016, the Department of Justice (DOJ) issued interim final rules increasing the civil penalty to $10,781 to $21,563. This may not sound like much, but these are penalties per claim. So if the $100,000 worth of false claims was comprised of 100 individual Medicare reimbursement claims, then your practice faces between $1.05 million and $2.1 million in penalties.

How Can Med USA Help?

As a practice, significant time is paid towards managing patients, personnel, systems, material, operations, bookkeeping, and reports. A trusted business partner is important to running a successful and profitable practice. However, as a medical professional, you understand the importance of mitigating risk at all levels.

Med USA’s experience and longevity in the RCM space can help provide the solution. Operating for 38 years, we have proven longevity in mitigating risk and providing our clients peace of mind. For example, Med USA’s proprietary PM (Practice Management) software manages scheduling, demographics, billing and claims submission, and reporting and is used daily by our own staff to provide RCM services. One of Med USA’s competitive advantages is our proprietary software and our ability to rapidly adapt to payer rules and regulations.  In addition to our software, Med USA’s RCM support team has unprecedented tenure in the RCM industry. Because Med USA is a privately owned and operated company you can count on a client-centric approach to service and support that permeates throughout the company.

Contact Med USA by visiting our website to schedule a complimentary review and a demo of our products and services.

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