Five federal fraud and abuse laws impacting physicians are critical for compliance, according to a March 19 blog post from the National Rural Health Association.
Here are the five laws, as outlined by the organization:
False Claims Act
The False Claims Act prohibits knowingly submitting false or fraudulent claims to Medicare or Medicaid. Penalties include fines up to three times the program’s loss plus $11,000 per claim filed.
Common violations include billing for services not provided, performing unnecessary procedures and submitting inflated invoices. Unbundling, the act of using multiple billing codes instead of one, and upcoding, the act of assigning more severe diagnosis codes, are also violations.
Additionally, providers who falsify physician signatures for reimbursement face severe consequences.
Anti-Kickback Statute
The Anti-Kickback Statute is a criminal law that bans offering, paying, soliciting or receiving remuneration to induce patient referrals for services covered by federal health programs.
Violations include cash bonuses for referrals, free or below-market rental space, and excessive compensation for speaking engagements. Penalties range from fines and jail time to exclusion from federal health programs.
Stark law
Stark law prohibits physicians from referring Medicare or Medicaid patients for designated health services to entities in which they have a financial interest unless an exception applies.
Violations include receiving compensation for referrals, accepting excessive payments for services and referring patients to owned entities. Unlike the AKS, which applies to all referrals, Stark law is a civil statute with financial penalties and exclusion from federal programs.
Exclusion statute
The Office of the Inspector General mandates exclusion from federal health programs for individuals convicted of Medicare or Medicaid fraud, patient abuse or felony healthcare-related offenses. Excluded providers cannot bill for services, and federal programs will not reimburse services furnished, ordered or prescribed by them.
Civil Monetary Penalties Law
The OIG enforces the Civil Monetary Penalties Law against misconduct such as submitting false claims, engaging in Anti-Kickback Statute violations and making misleading statements on program applications. Violations can result in hefty fines and program exclusion.