Every year, the government reclaims billions of dollars from illegal billing. Most of these claims involve healthcare. TheFalse Claims Act (FCA)is a powerful law to fight against fraud, waste, and abuse.
In this module, you will learn about the purpose and benefits of the FCA. We will discuss how to report potential false claims and the penalties for violations.
Please look at the important terms before you begin.
Civil monetary penalty (CMP)
A fine charged to a facility when it violates certain laws and rules
Claim
According to the False Claims Act, “any request or demand for money or property”
Corporate integrity agreement (CIA)
An agreement made to prevent exclusion from the federal healthcare programs
Exclusion
To prevent from participating or entering a federal healthcare program
False claim
A claim for money or property that is not true or owed
Fraud
Cheating to gain money or property
Qui tam provision
Part of the False Claims Act that allows any person to file a lawsuit for the government
Retaliate
To do something against someone to get revenge
Reverse false claims
Overpayments from a federal healthcare program that are not paid back
Violation
Not following a law or rule
Whistleblower
Person who files a false claims lawsuit for the government
The False Claims Act (FCA) is a federal law that makes it illegal to send a false claim to the government. The law is effective in getting payments back that were made for false claims. This protects and benefits both federal healthcare program recipients and taxpayers.
The FCA applies to people and facilities that knew or should have known that a claim was false. Any claim that is incorrect or false can be a violation. Single mistakesare usually not treated as fraud.Repeating the same erroris a violation of the FCA. There are many ways that claims can be false. Here are examples of false claims:
Billing for unneeded services
Assigning higher-level codes on bills, with higher-level payments
Failing to provide medical record data to support a claim
Federal law requires your facility to have a compliance program.
The program is designed to help discover, prevent, and correct illegal and unethical actions.
A strong compliance program creates benefits for healthcare facilities and the individuals they care for. These benefits include better quality of care and lower costs.
Healthcare facilities have a legal duty to send correct claims. They also need to protect individuals' health data.
A strong compliance program shows that the facility:
Report when you:
See something that does not seem right.
Have questions about a sensitive issue.
Are not sure if a problem exists but have concerns.
As a healthcare worker, you have a duty to speak up if you see or hear a concern.
Values honest behavior.
Encourages staff reporting.
Seeks to discover illegal or unethical actions.
Seeks to prevent illegal or unethical actions.
The focus of a compliance program should be on the facility-specific areas of risk.
All staff are required to take compliance training on a regular basis to keep the rules in mind.
Almost all health data is confidential. Never look up or talk about an individual’s health data unless it is part of your job.
Codes are standard numbers and letters that stand for different types of illnesses and procedures. Codes should correctly match the data that is documented in the health record.
Billing for services that were not needed or not done is illegal. All care given to individuals should be needed to improve their health. This rule also applies to medical items.
The Stark Law, or physician self-referral law, says that it is illegal:
For doctors to make referrals for designated health services (DHS) if the doctor (or their close family member) has a financial contract with the DHS business.
For the facility the doctor works for to send claims for those referred services.
Examples of DHS include lab tests and physical therapy.
The federal Anti-Kickback Statute says that it is illegal to give or take money or
something of value for referrals.
EMTALA is a law about care in Emergency Departments. EMTALA is sometimes called the anti-dumping law.
The law says that all people can get emergency care, even if they cannot pay for it. This includes a woman in labor.
The FCA says that a provider cannot send a claim for payment that is not true.
Examples of the FCA include:
When a provider submits a claim for services they did not give.
When a provider submits a claim for a higher level of service than they gave to an individual.
A conflict of interest is when a person gets personal benefit from job-related choices or actions. Check your facility’s policies and procedures before taking gifts from business partners.
Duty to Report
Lesson 5 of 6
Federal law protects those who report in good faith.
Trying to get revenge against someone who reported a concern is illegal.
Give a detailed report of what you saw and heard.
Report names, dates, times, and locations.
Check your facility’s policies and procedures for ways to report. Here are a few options:
Talk to your manager.
Talk to your compliance officer.
Use your facility’s compliance hotline for reporting.
Choose the best option and select SUBMIT.
There is no right reason to take money from a person in your care. Following the coworker or telling others will not help. It is your duty to report.
If you saw a coworker take money from a person in your care, what should you do?
Assume they are taking it for safekeeping.
Follow them to see where they go.
Report what you saw to your manager.
Tell your other coworkers.
seven parts of a compliance program
Regular, useful training for staff
Regular, useful training for staff
Written standards of behavior and policies and procedures
A way to make sure the program works and for people to report privately
A compliance officer who has the right skills and knowledge
A way to find problems and solve them
A way to prevent hiring people who have broken the law
