Billing, News, Skilled Nursing Facility

Tip: Audits and the False Claims Act’s far reach

If the results of an internal audit determine that Medicare was billed inappropriately, the provider is in potential violation of the False Claims Act, which describes a violator as any entity or person that causes the federal government to make payments for goods or services that are a) not provided, b) provided contrary to federal standards or law, or c) provided at a level or quality different than what the claim was submitted for.

In other words, Medicare-participating providers are in violation of the False Claims Act if they submit Medicare bills, and are paid, for care that is deemed any of the following:

  • Inappropriate
  • Unnecessary
  • Misrepresented (e.g., through upcoding or false documentation)
  • Not provided

If an internal audit reveals any of these issues with submitted Medicare claims, a False Claims Act violation is likely in play. Once a provider discovers such a transgression, it is obligated under federal law to report, or self-disclose, the activity.

As defined by the Office of Inspector General (OIG), self-disclosure is a “process for health care providers to voluntarily identify, disclose, and resolve instances of potential fraud involving the Federal health care programs.” The OIG maintains a designated protocol to help providers achieve these aims.

Adhering to self-disclosure expectations can help providers ward off civil monetary penalties (CMP) and other federal repercussions, not to mention extensive legal costs.

The benefits of the practice do have their limits, though. Self-disclosure cannot be used to mitigate penalties for activities considered criminal, nor is it appropriate for overpayments, which are handled directly by the fiscal intermediary.