Medicare fraud costs the government billions of dollars every year. Perpetrators include doctors, nurses and other health care professionals, although some are unaware of any involvement.
The aim of three specific federal laws is to protect the government against various forms of Medicare fraud.
1. The Anti-Kickback Statute (AKS)
The AKS states that it is unlawful to “knowingly and willfully offer, pay, solicit, or receive any remuneration directly or indirectly to induce or reward patient referrals or the generation of business involving any item or service reimbursable by a Federal health care program.” A doctor may legally provide discounted or even free services to uninsured patients. However, if the physician routinely waives copays, he or she might be in violation of the AKS.
2. The Federal Civil False Claims Act (FCA)
The purpose of the FCA is to protect the federal government “from being overcharged or sold substandard goods or services.” For example, if a doctor’s staff submits a false claim, whether or not they know it to be fraudulent, they violate the FCA and may have to pay a penalty of up to $22,927.
3. The Stark Law (Physician Self-Referral Law)
According to the Stark Law, physicians may not refer Medicare patients to facilities where they have a personal interest and could receive a referral fee. This means offices, hospitals, labs or other entities in which physicians or their immediate family members have a financial interest. Those who violate the Stark Law face penalties up to $24,478 per service referral and may lose their ability to participate in federal healthcare programs. Since there are some exceptions, the best way forward for health care professionals is to become familiar with the Stark Law, the AKS and the FCA in order to avoid any legal missteps.