FALSE CLAIMS ACT
The civil FCA protects the Government from being overcharged or sold shoddy goods or services. It is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent. Filing false claims may result in fines of up to three times the programs’ loss plus $11,000 per claim filed. Under the civil FCA, each instance of an item or a service billed to Medicare or Medicaid counts as a claim, so fines can add up quickly. The fact that a claim results from a kickback or is made in violation of the Stark law also may render it false or fraudulent, creating liability under the civil FCA as well as the AKS or Stark law. Under the civil FCA, no specific intent to defraud is required. The civil FCA defines “knowing” to include not only actual knowledge but also instances in which the person acted in deliberate ignorance or reckless disregard of the truth or falsity of the information. Further, the civil FCA contains a whistleblower provision that allows a private individual to file a lawsuit on behalf of the United States and entitles that whistleblower to a percentage of any recoveries. Whistleblowers could be current or ex-business partners, hospital or office staff, patients, or competitors. There also is a criminal FCA (18 U.S.C. § 287). Criminal penalties for submitting false claims include imprisonment and criminal fines. Physicians have gone to prison for submitting false health care claims.
AFFORDABLE CARE ACT
The Affordable Care Act (ACA) is a comprehensive reform law, enacted in 2010, that increases health insurance coverage for the uninsured and implements reforms to the health insurance market. Under the Affordable Care Act, patients who may have been uninsured due to preexisting conditions or limited finances can secure affordable health plans through the health insurance marketplace in their state.
The ACA:
• Expands health insurance coverage to 32 million more Americans by 2019.
• Provides Medicare bonus payments for primary care physicians and general surgeons, as well as increased Medicaid primary care payments. • Increases geographic adjustments to Medicare physician payments in portions of 42 states and territories. • Provides small business tax credits, for which many physician practices are eligible to apply, to assist in the purchase of health insurance for employees. • Replaces some of the worst excesses and abuses of the health insurance industry with strong consumer protections and administrative simplification provisions. • Prevents denials of care and coverage, including those for pre-existing conditions. • Makes health insurance more affordable for families and small businesses through the creation of state health insurance exchanges and the provision of sliding-scale premium tax credits and cost-sharing subsidies.
La State Med Soc NEW PHYSICIAN’S GUIDE 33
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