FWA Laws and Penalties

Each year the US government and private insurers strengthen their research and criminally processed many professionals. Since 2007, federal agencies have processed more than 2,300 providers imposing penalties ranging from 4 to 50 years in prison.

Did you know which laws will apply to you by committing FWA in US and its territories?

·         False Claims Act (FCA)

This Act imposes penalties on any person who knowingly submits, or causes the submission of, a false or fraudulent claim. The “knowing” standard includes acting in deliberate ignorance or reckless disregard of the truth related to the claim. The penalties includes, fines of $5,500–$11,000 per false claim and up to three times the amount of damages sustained by the government as a result of the false claims. There is also a criminal FCA statute by which individuals or entities that submit false claims can face criminal penalties.

Example: A physician submits claims for a higher level of medical services than actually provided or that the medical record documents.

·         Anti-Kickback Statute (AKS)

The AKS makes it a criminal offense to knowingly and willfully offer, pay, solicit, or receive any remuneration directly or indirectly to induce or reward referrals of items or services reimbursable by an insurance.

Example: A provider receives a discount in the rent for medical offices in exchange for referrals.

Penalties: Civil penalties for violating the AKS can include fines up to three times the amount of kickback. Criminal penalties for violating the AKS can include fines, imprisonment, or both.

• Physician Self-Referral Law (Stark Law)

The Law prohibits a physician from making a referral for certain designated health services to an entity in which the physician (or member of his or her immediate family) has an ownership/investment interest or with which he or she has a compensation arrangement, unless an exception applies. Penalties include fines, repayment of claims, and potential exclusion from participation in any insurance.

Example: A provider refers a beneficiary to a lab in which the provider has an investment interest.

·         Criminal Health Care Fraud Statute

It prohibits knowingly and willfully executing, or attempting to execute, a scheme or artifice in connection with the delivery of or payment for health care benefits, items, or services to:

Ø  Defraud any health care benefit program; or

Ø  Obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program.

Example: Several doctors and medical clinics conspire in a coordinated scheme to defraud health insurances by submitting claims for power wheelchairs that were not medically necessary.

Penalties for violating may include fines, imprisonment, or both.

Top FWA incidence states

Texas

Florida

California

New York

Illinois

Recoveries

By the end of fiscal year 2014 the agencies responsible for the prevention of fraud, waste and abuse recovered 3.3 billion from providers who attempted to defraud health insurances.

“As the innovative and collaborative work of the Health Care Fraud and Abuse Control Program proceeds, more taxpayer money is being recovered, more criminals are facing justice, and more fraud is being punished, prevented, and deterred,” said Attorney General Holder