Facts about the False Claims Act
As the name implies, the False Claims Act (FCA) makes it illegal to knowingly submit or cause the submission of a false or fraudulent claim to the federal government.
The False Claims Act protects the federal government from being overcharged or sold substandard goods or services. The civil FCA imposes civil liability on any person who knowingly submits, or causes the submission of, a false or fraudulent claim to the federal government. Civil penalties for violating the civil FCA may include recovery of up to three times the amount of damages sustained by the government as a result of false claims, plus financial penalties per false claim filed. Additionally, under the criminal FCA, individuals or entities may face criminal penalties for submitting false, fictitious, or fraudulent claims, including fines, imprisonment, or both.
The Terms “Knowing” and “Knowingly” indicate a person has actual knowledge of the information or acts in deliberate ignorance or reckless disregard of the truth or falsity of the information related to the claim.
In fiscal year 2021, the justice department recovered over $5.6 billion for violations concerning providers intentionally submitting claims for medically unnecessary procedures; billing for procedures that were not performed; using non-credentialed providers for report interpretations of test results; distributing fraudulent prescriptions; and violations of the anti-kickback statute -- which is when a provider offers, pays, solicits, or receives unlawful compensation.
Violating the FCA may result in civil liability and/or financial penalties such as:
- Triple damages for the billed amount
- Civil penalties for $10,000 to $20,000 or more per false claim
- Government-mandated compliance sanctions
- Criminal prosecution
- Loss of medical license
Example of the False Claims Act violation
The United States and the state of Florida alleged that from April 1, 2020, through Nov. 8, 2021, Physician Partners of America (PPOA) submitted or caused the submission of false claims to Medicare for medically unnecessary evaluation and management (E/M) services for medically unnecessary telemedicine services. The increased number of E/M telemedicine visits was designed to make up for lost revenue from the cancellation of elective interventional pain procedures. PPOA was accused of using telemedicine during the COVID-19 pandemic to allegedly try and compensate for revenue lost from elective services. The United States and the state of Florida further contends that physicians subsequently scheduled appointments every two weeks regardless of patient need, resulting in increased billings and revenue.
Physician Partners of America and two of its leaders will pay $24.5 million to resolve False Claims Act allegations.
This case and others illustrate the importance of ensuring that your documentation supports medical necessity for the services you provide. Good documentation helps address any challenges raised about the integrity of your claims. “If you didn’t document it, it’s the same as if you didn’t do it.”
If you have questions or concerns regarding fraudulent activities or the False Claims Act, please contact OPCC at (203) 688.8416 or email [email protected] or [email protected].
