Medicare fraud
regulationso help identify unnecessary tests.
The Medicare website warns that a few people are out to defraud the program and that losses can total millions of dollars a year. Medicare fraud costs everyone money, removes funds that could be used to help more people and forces increases in Medicare premiums. Knowing the Medicare fraud regulations can help control Medicare fraud.
False Claims Act
The False Claims Act targets any person or company that knowingly files a false claim for payment or makes statements that help move along the processing of a false claim. The fine is up to three times the amount of the government's damages plus civil penalties. This act does not include tax fraud and is subject to whistleblower provisions to protect citizens who provide proof of false claims. The whistleblower may be entitled to a percentage of the funds recovered. (References 1 and 2)
Anti-Kickback Statute
The Anti-Kickback Statute was passed by Congress to address concerns about money influencing health care decisions. The concern was that people may get poor, unnecessary or medically inappropriate care due to the influence of kickbacks or bribes. According to the Office of the Inspector General Fact Sheet, "anyone who knowingly and willfully receives or pays anything of value to influence the referral of federal health care program business, including Medicare and Medicaid, can be held accountable for a felony." Violators of the Anti-Kickback law can be fined up to $50,000 and be excluded from participating in federal health care programs. Because this law is so broad, in 1987 Congress passed the "Safe Harbor" regulations for some payment and business practices. This statute also falls under whistleblower guidelines. (Reference 3)
Stark Statute
The Stark Statute was passed by Congress to address physician referrals. The Stark Statue was enacted in three parts referred to as Stark I, II and III. According to the Medscape Today website, the statute applies to physicians who refer Medicare and Medicaid patients for health-care services in which they (or an immediate family member have a "financial relationship." Violations of the Stark Statute are punishable by a fine of $15,000 per claim or three times the amount of the claim. Circumvention schemes are punishable up to $100,000 in civil penalties. This statute also uses the whistleblower guidelines. (Reference 4)
Tags: Medicare fraud, health care, Stark Statute, Anti-Kickback Statute, civil penalties