There are three important federal laws that apply to healthcare fraud and abuse: The False Claims Act, the Stark Law and the Anti-Kickback Statute are three federal laws which govern other forms of compensation for doctors. Healthcare providers must navigate the complicated laws and potential regulatory pitfalls to make sure that their business is operating in compliance with the law. The Department of Justice, the Department of Health and Human Services Office of the Inspector General, and the Centers for Medicare & Medicaid Services (CMS) are tasked with enforcing these laws, but they rely on private citizens and private attorneys to act as their “eyes and ears,” and they compensate citizens who are helpful.
False Claims Act (FCA) [31 U.S.C. § § 3729-3733]
The purpose of the False Claims Act is to protect the government from being defrauded. Knowingly submitting a false claim for payment to Medicare or Medicaid, for example, carries hefty fine of up to three times the program’s loss plus $11,000 per claim filed. Civil charges under the FCA do not require any proof of intent to defraud; the act of knowingly defrauding is enough. Criminal penalties for FCA violations include prison time and fines.
An important provision of the FCA allows private citizens to file enforcement actions if they should become aware of claims that are being submitted fraudulently, and they may be eligible to receive up to 30% of the recovery.
Stark Law [42 U.S.C. § 1395nn] (Physician Self-referral law)
Stark law, according to Starklaw.org, is “actually three separate provisions, [which] governs physician self-referral for Medicare and Medicaid patients.” Named for the U.S. Congressman who sponsored the Bill, Pete Stark, the law intends to make sure that physicians are unable to generate additional revenue by referring patients to another medical facility in which they have a financial interest.
Anti-Kickback statute [42 U.S.C. § 1320a-7b(b)]
The Anti-kickback law (AKS) “is a criminal law which forbids the knowing and willful payment of “remuneration” to induce or reward patient referrals, or any scheme to generate products or services payable by the federal health care programs,” per the Office of Inspector General of the U.S. Department of Health & Human Services. The OIG defines remuneration as anything of value including free rent, hotel stays, meals, excessing compensation for medical directorships or consultancies. The OIG reminds doctors that rewarding those who refer business to you is a federal crime, and that doctors must be aware that they are attractive targets for kickback schemes.
Recent Stark Law and FCA settlements
- Tri-City Medical Center of Oceanside, CA has agreed to pay the federal government more than $3.2 million to settle Stark Law and FCA violations.
- Rose Radiology of Tampa, FL settled FCA allegations for $8.7 million
- Kindred Healthcare agreed to pay the federal government $125 million to settle allegations it knowingly allowed skilled nursing facilities to submit false claims to Medicare. (Becker’s Hospital Review)
While following the law is always the right thing to do, if healthcare providers violate these laws (knowingly or unknowingly) they may face significant civil and criminal penalties, and even exclusion from participation in federal health care programs. Doctors may also lose their medical license if convicted.
If you think that it is time to report your employer for violating Arizona’s anti-kickback statute, you should consider speaking to one of our experienced qui tam lawyers first so that you can get a clear understanding of what is at stake. At Plattner Verderame, P.C., our Phoenix quit tam attorneys understand the law, we have experience working with the DOJ, and what reward is likely given the facts of your case. Please phone us at 602-266-2002 to schedule a consultation. We can also be reached confidentially through our contact form.