Healthcare Fraud And The False Claims Act (FCA)

The False Claims Act makes it illegal to knowingly submit, or cause to be submitted, false claims for payment to the US Government. Many states have enacted their own False Claims Acts which may be even more stringent that the federal Act. The majority of False Claims Act investigations and prosecutions involve healthcare fraud.


For a short video on fraud, waste and abuse, please click here.

Types of Healthcare Fraud

The following are various examples of fraud in healthcare:

  • Kickbacks
  • False price reporting practices
  • Illegal or inaccurate pricing
  • Billing for unnecessary drugs, procedures, devices, or medical equipment
  • Upcoding
  • Unbundling


Who Is Liable Under The FCA?

At its most basic, FCA liability attaches to any person who knowingly presents or causes to be presented to the government a false or fraudulent claim for payment or approval.

  • The FCA does not require that the person submitting the claim have actual knowledge that the claim is false
  • A person who acts with “reckless disregard” or “deliberate ignorance” that the claim is false is also liable under the FCA


Who Can Bring A False Claim Act Complaint?

The False Claims Act contains a unique “qui tam” provision that allows private citizens with evidence of fraud to file a lawsuit on behalf of the government. The US Department of Justice can join the individual’s lawsuit on behalf of the government. In these cases, numerous federal and state agencies may be involved in the case including the DOJ, FBI and state governments.


Avoiding FCA Liability

Here are examples of ways to avoid FCA liability:

  • Ethical Interactions with HCPs
  • Compliance educational presentations
  • Providing only accurate information
  • Reporting any actual or suspected instance of unethical behavior that could constitute health care fraud or FCA violations


Situations Of Fraud, Waste And Abuse


Situation 1

A superstar marketer keeps very sketchy expense records. The boss lets him get away with this because he’s such a big producer. Is this acceptable?


No. Everyone is responsible for following policies and procedures for the company no matter what their role is. Inappropriate expenses could be cause for fraud, waste, and abuse and should be reported.


Situation 2

Your supervisor asked you to code up on your ADLs so that you can get a higher RUG when billing for services. You know that these ADLs are not appropriate for this resident and the work you performed. Do you code the ADLs anyway?


No. You should never upcode just for higher payment. You should only code what you provided. This would be considered fraud, waste, and abuse.