Medicare Compliance & Reimbursement

Learn these federal no-nos and prevent unwitting fraud.

When the government cracks down on False Claims Act (FCA) violations, they consistently prosecute these 4 trip-ups. Providers should monitor their claims carefully through each step of the submission process, or they could be accused of federal charges before you even know there's billing amiss. They should keep an eye out for these transgressions: 1. Submitting false claims. According to the FCA, the government doesn't even need to prove that providers personally intended to defraud anyone to pin this violation on them. They hold providers ultimately accountable, and that includes people working for providers - and yes, that means third-party consultants, too. So even if a consultant is to blame for less-than-sparkling claims, providers can't get away with pointing fingers at him. Because most FCA complaints are reviewed for both civil and criminal transgressions, any discovery of fraudulent intent could score you criminal liability. 2. False statements or records accompanying claims. Proving this infraction is a little trickier. The prosecutor's burden of proof is threefold: she must prove a provider filed a false claim, that he created or used phony records or statements to get the claim approved, and that he performed all these acts "knowingly and willfully." 3. Conspiracy to submit false claims. This violation is composed of several conditions. First, a provider must have the intent to defraud the government, demonstrate agreement or action toward filing a false claim, and get the false claim reimbursed by the government. 4. Reverse false claims. This rule makes liable anyone who creates or uses a fake record or statement to cover up, evade, or reduce his responsibility to remit money or property to the government. The "knowingly and willingly" clause applies to all of these provisions, meaning in order to be considered guilty of the offense, providers must know about the information in question and either purposely ignore or recklessly disregard its truth or falsity.