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Complete Guide To the False Claims Act for Healthcare Practices

As the name implies, the False Claims Act in the healthcare sector prohibits workers from submitting fraudulent claims. In other words, healthcare practices must not bill the government for things they did not do.

As a healthcare practice, you can typically submit claims to Medicare or Medicaid. Your claims are bills for goods you provide and services you conduct for patients. These federal health insurance programs cover the costs associated with your services.

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False Claim Act Components

There is a civil component and a criminal component to the False Claim Act:

Civil False Claim Act

Under the FCA’s civil component, you can be guilty of making a false claim even if you did not consciously attempt to defraud the government. This component exists to protect the government from overcharges.

For instance, suppose you are a physician, and you bill a federal healthcare program for a list of medical services you allegedly performed. In reality, there were a couple of items you neither conducted yourself nor participated in its execution.

In this example, the civil FCA would take effect because you may have not meant to charge the federal healthcare program for all the services on the list. Perhaps you made an error in the billing, thus overcharging the government.

Relatedly, each item counts as a claim. So, every false claim would stack in fines. Fines under the civil FCA reach up to three times the federal health care programs’ loss. Plus, each filed claim may cost $11,000.

Meanwhile, this FCA component includes a whistleblower provision. So, current or former business partners, hospital staff members, patients, or even competitors may report your alleged false claims. The provision entitles the whistleblower to a percentage of potential recoveries from the lawsuit against you.

Criminal False Claim Act

The FCA’s criminal component is more serious than the civil component in terms of provisions and fines. In general, this constituent involves healthcare workers who intentionally attempt to defraud the government.

Bringing back the above example, you are a physician, and you bill a federal healthcare program for a list of medical services you allegedly conducted. However, you fabricated the items on the list and then submitted the claims for reimbursement, knowing they are fake and you never performed or collaborated in them.

Should the federal government find you guilty, you can face extensive jail time. The U.S. code on criminal penalties for acts involving federal health care programs (42 U.S. Code § 1320a–7b) states that you could spend up to ten years in prison. At the same time, you could pay up to $100,000 in fines. Some physicians can lose their licenses entirely.

Examples of False Claims

Healthcare fraud can involve individuals or groups of healthcare workers misrepresenting their services and end up overcharging the government. The United States Department of Justice listed a few instances of healthcare fraud.

Billing for Services Not Rendered or Goods Not Provided

You cannot submit claims for medical services that you did not perform, treatments you did not offer, diagnostic tests you did not conduct, medical devices you did not use, or pharmaceuticals that you did not render. Regardless of the extra cost that you may earn from the false claims, you could get fines of up to three times the government’s loss.

Falsifying Certificates of Medical Necessity and Billing for Services Not Medically Necessary

It is illegal to charge federal insurance companies for unnecessary medical services. Should the government discover that you billed them for performing a medical exam or prescribing medicine that the patient did not need, you could face charges for making a false claim.

Billing Separately for Services That Should Be Included in Single Service Fees

Be sure to combine bills for services that you need to combine. Some physicians may attempt to defraud the government by separating the bills for multiple services under one package.

Individual going over falsified documents

Falsifying Plans of Treatment or Medical Records to Justify Payments

This scheme may fall under the criminal component of the FCA. You could face severe charges for creating fake supporting documents in an attempt to validate your false claims.

Misrepresenting Diagnoses or Procedures to Maximize Payments

Some physicians may misrepresent the diagnoses of their patients, meaning they would exaggerate their patient’s condition to maximize the return they receive from the federal health insurance provider. This tactic can be related to falsifying medical certificates.

Misrepresenting Charges or Entitlements to Payments in Cost Reports

This fraudulent method may be related to billing for medical services and goods that you did not render or provide. In this case, a fraudulent physician would falsify their entitlements to reimbursements.

Soliciting “Kickbacks” for the Provision of Various Services or Goods

The law prohibits physicians from receiving solicitations or “kickbacks” for referring their patients to federal health programs. Kickbacks include money and anything of value. For example, as a physician, you refer your patient to a facility that bills their services to Medicaid. That facility pays you for referring a patient to their services. The law prohibits such behavior, meaning you would have committed healthcare fraud.


Remember, colleagues or patients can report you for making false claims, should they discover your fraudulent behavior. If you believe you are facing a case associated with the FCA, you should get legal assistance to protect your medical practice. For more information on how the False Claims Act for healthcare industry business owners works, get in touch with our experts — this is our specialty and we’d be happy to help.