False Claims Act Prevention
What is the Federal False Claims Act?
The Federal False Claims Act is a federal statute that establishes liability for knowingly presenting a false or fraudulent claim for payment to the United States government or to a government contractor. This includes claims submitted to Medicare or Medicaid.
Violating the False Claims Act is a very serious matter. Health care providers and their employees can be subject to civil monetary penalties of $5,500 to $11,000 for EACH false claim submitted. They can be required to pay three times the amount of damages sustained by the United States government, and they may also be excluded from participation in Medicare and Medicaid.
The New York State Social Services law also imposes fines for fraudulent billing practices. Billing fraud is a serious crime and may be punishable by imprisonment.
What kinds of conduct may violate the Act?
Examples of practices that may violate the False Claims Act if done knowingly and intentionally, include the following:
- Billing for services not rendered
- Knowingly submitting inaccurate claims for services
- Taking or giving a kickback for a referral
How is URMC and its affiliates preventing violations of the False Claims Act?
The Compliance Office has an extensive program for detecting and preventing fraud, waste and abuse as well as violations of the Federal False Claims Act. These policies are described in the Plans and Policies section of this web site.
How can I help avoid violations of the False Claims Act?
There are several things you can do to reduce the risk of False Claims Act liability. First, you should make sure you understand the rules that relate to the services and goods being billed. Information contained in any claim must be as accurate and complete as possible. Specifics about correct billing may be obtained from:
- The Centers for Medicare and Medicaid Services
- The New York State Medicaid program
- Medicare Administrative Contractor - National Government Services, Inc.
- The New York State Department of Health
You may also receive assistance from the Compliance Office by calling (585) 275-1609.
Second, if you become aware of a potential billing problem, you should immediately notify your supervisor, the Compliance Office or the Integrity Hotline, (585) 756-8888. It is important to act swiftly so the matter can be reviewed and the proper action taken. Potential actions include:
- Making changes to prevent the problem from continuing
- Making arrangements to repay any overpayments
- When appropriate, disclosing the problem to appropriate state and federal officials
By voluntarily disclosing such information, URMC or its affiliate may be able to avoid liability or at least limit liability under the False Claims Act.
Am I protected from retaliation?
State and Federal law and URMC policy contain protections against retaliation for disclosing potential billing problems. These protections may include employment reinstatement and back pay. Additionally, the Compliance Office operates a hotline that makes it possible for you to make your concerns known without disclosing your identity.
The False Claims Act also includes a “qui tam” provision that allows any person with actual knowledge of a False Claims Act violation to file a lawsuit on behalf of the United States Government. If the government determines that the lawsuit has merit and decides to join, the United States Department of Justice will direct the prosecution of the lawsuit. If the government decides not to join in the lawsuit, the person who filed the lawsuit on behalf of the government can continue the lawsuit on his or her own.
Call with any concerns about improper, unethical or non-compliant activities.