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3 laws that govern an investigation for possible Medicare fraud

On Behalf of | Jun 14, 2022 | Government Fraud

Healthcare professionals in Florida have a ready supply of elderly patients with Medicare insurance coverage.

However, Florida has also gained a reputation for Medicare fraud. Here are three laws that can play a role in an investigation pertaining to this kind of crime.

The Federal Civil False Claims Act (FCA)

In the words of the Centers for Medicare & Medicaid Services (CMS), the FCA “imposes civil liability on any person who knowingly submits, or causes the submission of, a false or fraudulent claim” to a healthcare program the government operates. Penalties include up to three times what a fraudulent claim is worth plus up to $22,927 per claim.

The Stark Law

Under the Physician Self-Referral Law, or Stark Law, healthcare providers cannot refer patients to another medical office or facility in which they or their close family members have a personal interest. For example, a physician cannot refer a patient to a certain lab in return for a referral fee. However, the Stark Law permits a physician to refer a patient to another physician in the same practice. A healthcare professional who violates this law could pay a penalty of up to $24,478 per infraction.

The Anti-Kickback Statute (AKS)

Under the AKS, a healthcare professional cannot “knowingly and willfully offer, pay, solicit or receive any remuneration directly or indirectly to induce or reward patient referrals.” Remuneration could be anything from free services to luxury vacations. Those guilty face penalties of up to three times the kickback value and fines as high as $100,000 per kickback. Criminal penalties can include prison time.

Seeking help

A healthcare professional who is the target of an investigation for Medicare fraud usually becomes aware of the probe in advance. This is the time to seek legal assistance and begin building an effective defense strategy.


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