Medicare fraud can occur in small practices, large medical offices, hospitals, pharmacies and a variety of other healthcare-related companies and facilities.
This type of fraud costs the U.S. government billions of dollars each year. Here are three federal laws that govern the investigation into Medicare fraud.
Federal Civil False Claims Act (FCA)
The Centers for Medicare and Medicaid Services (CMS) explains that the FCA “imposes civil liability on any person who knowingly submits, or causes the submission of, a false or fraudulent claim” to a government healthcare program. This means that whether the person who submits the claim knows it is fraudulent or submits such a claim unknowingly, the action violates the FCA. Penalties include up to $22,927 per fraudulent claim and a further payment equal to three times the value of each fraudulent claim.
This law prohibits a healthcare provider from referring those covered by Medicare to any facility in which the provider or an immediate family member has a personal interest. There are exceptions; for example, it is acceptable for a physician to refer a Medicare patient to another doctor within the same practice. A healthcare provider who violates the Stark Law may have to pay a fine of up to $24,478 per the fraudulently referred service.
Anti-Kickback Statute (AKS)
Through the AKS, it is illegal to “knowingly and willfully offer, pay, solicit, or receive any remuneration directly or indirectly to induce or reward patient referrals” involving a federal healthcare program. The remuneration could be a monetary payment or a reward in the form of a luxury item or discounted item or service. Fines are up to $100,00 per kickback along with possible prison time. Creating a suitable defense strategy is the next step for anyone facing investigation for the possible violation of this or any other Medicare fraud law.