In the post-COVID era, health care fraud and abuse issues will be aggressively and swiftly enforced by the government. The legal framework and regulations in the health care space can be intimidating. Below is a comparison of three of the big federal fraud and abuse laws that the government actively enforces; but they are not an exclusive list. The summary below is a primer on the three main federal fraud and abuse laws and is intended to increase your basic understanding of these laws.
False Claims Act (FCA)
PROHIBITIONS:
- Prohibits the submission of false or fraudulent claims, false statements material to a false claim, and conspiracy to commit violation
- Prohibits concealing or avoiding obligation to repay money to government (failure to return overpayments)
- Claims that violate AKS or Stark can also be considered false claims
- Common false claims include lack of medical necessity; quality of care; billing/coding issues; off-labeled marketing; retention of overpayments
EXCEPTIONS:
PENALTIES:
- Treble damages and as of May 9, 2022 per claim penalties between $12,537 and $25,076
- Regulated by the DOJ
Physician Self-Referral (Stark)
PROHIBITIONS:
- Prohibits referrals of designated health services by a physician (or an immediate family member) if the physician has a financial relationship with the entity performing the designated health service
- Regulates financial relationships with physicians (and physician's immediate family members) only
EXCEPTIONS:
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