Understanding the False Claims Act

Sep 3, 2024

Lecture Notes: Introduction to the False Claims Act (FCA)

Speaker

  • Katie Fink, Attorney at the Office of the Inspector General

Overview of the False Claims Act (FCA)

  • The FCA helps recover money for the government from false or fraudulent claims for payment.
  • Applies to claims submitted to government programs like Medicare and Medicaid.

Examples of False Claims in Healthcare

  • Services not rendered to the patient.
  • Services provided but already covered under another claim.
  • Upcoded claims.
  • Claims not supported by patient medical records.
  • Claims resulting from violations of the Federal Anti-kickback statute or the Stark law.

Government's Approach to FCA Violations

  • Targets knowing or should have known false claims.
  • "Should have known" includes deliberate ignorance or reckless disregard.
  • Providers must be proactive to ensure compliance, such as through internal audits.

Obligations on Providers

  • Innocent billing mistakes require repayment to the government.
  • The Affordable Care Act mandates repayment of overpayments within 60 days, or face penalties.

Consequences of FCA Non-Compliance

  • Penalties up to three times the program’s loss, plus $11,000 per claim.
  • Each claim is a separate liability ground.

Whistleblowers

  • FCA incentivizes whistleblowers with up to 30% of recovery.
  • Common whistleblowers include ex-business partners, current/former employees, competitors, or patients.

Notable FCA Cases

  • Involves large entities (drug and device manufacturers, pharmaceutical companies) and small entities/individuals.
  • Example: A cardiologist paid $435,000 and entered into a 5-year Integrity Agreement for unsupported claims and double billing.

Ensuring Compliance

  • Providers should have robust internal audit programs.
  • Must repay overpayments within 60 days if identified.
  • Disclosure of billing errors possible through the OIG Self-Disclosure Protocol.

Final Notes

  • Providers must consistently submit accurate claims to comply with the law.
  • Further reading and consultation advised for more information on FCA.