In sum, the federal False Claims Act makes it illegal to submit false or fraudulent claims for payment to Medicare, Medicaid or TriCare. There is also a California False Claims Act that makes it illegal to submit false or fraudulent claims for payment to private insurance companies. These types of cases are also called "qui tam" or "whistleblower" lawsuits.

 

Claims may be false if the service is not actually rendered to the patient, is provided but already covered under another claim, is miscoded, or is not supported by the medical record. Claims can also be false if improper referral fees or kickbacks were paid for the service

 

For example, a cardiologist was prosecuted under the False Claims Act for submitting claims for evaluation and management (E&M) services even though he had already received payment for the same services under previously billed stress test claims. He paid the Government $435,000 and entered into a 5-year Integrity Agreement.

 

For False Claims Act violations, you can be fined up to three times the program's loss, plus $11,000 per claim. And fines add up quickly because each claim

can be a separate ground for liability

 

 

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