Federal & State Regulations
The False Claims Act
A person who knowingly submits false or fraudulent claims to federal health care programs violates the False Claims Act (the FCA). The FCA violation can be either civil or criminal. For a civil violation, no proof of specific intent to defraud is required. Rather, the act includes situations where the submitter acts in deliberate ignorance or reckless disregard of the truth or falsity of the information. This means organizations can be liable if they ignore problems in their claims.
Violations of the FCA result in liability of up to three times the original claim, plus a penalty for each false claim filed.
The Anti-Kickback Statute
Simply put, it is a criminal offense under the federal Anti-Kickback Statute (the AKS) to knowingly offer, pay, solicit, or receive any remuneration to induce or reward a referral for any service under a federal health care program. Remuneration can mean anything of value, including money, benefits, etc. This law prohibits practices such as offering or receiving gifts for referrals that are common in other business sectors. If a provider intentionally pays something of value to obtain a referral for a patient, then they violate the AKS and in addition, the claims they submit for that patient violate the False Claims Act (FCA). The provider may face both FCA liability and criminal penalties for the AKS violation.
The No Surprises Act
The No Surprises Act is a federal law that went into effect in January 2022. This act protects patients from unexpected out-of-network medical bills.6 The goal of this act is to “help stop providers from gaming the system by evading the surprise billing rules with creative contractual loopholes that still leave consumers with unexpected costs.”
If patients are not using health insurance (either because they do not have it, or their insurance does not cover the treatment) they may request an estimate which must be provided three days in advance of the treatment. Providers are obligated to give these patients a good faith estimate of what their care will cost. Patients can dispute their bill if it is at least $400 more than the estimate.
Patients who are using health insurance are protected from out-of-network surprise bills for:
- Emergency room visits
- Non-emergency care in an in-network hospital, hospital outpatient department, or ambulatory surgical center
- Air ambulance services
The No Surprises Act also requires providers and facilities to give patients easy-to-understand notices that explain the applicable billing protections and who to contact if they have concerns.
Self-Referral Disclosure Protocol
Patient Protection and Affordable Care Act:
Section 6409 of the Patient Protection and Affordable Care Act (ACA) was signed into law on March 23, 2010. Section 6409(a) of the ACA required the Secretary of the Department of Health and Human Services, in cooperation with the Inspector General of the Department of Health and Human Services, to establish a Medicare self-referral disclosure protocol that sets forth a process to enable providers of services and suppliers to self-disclose actual or potential violations of the physician self-referral statute.
CMS Self-Referral Disclosure Protocol
Medicare Overpayments
An overpayment is a payment made by CMS to a provider that exceeds the amount due and payable according to existing laws and regulations. Identified overpayments are debts owed to the federal government. Laws and regulations require that CMS recover overpayments. Click link to view MLN Overpayment Fact Sheet: