The False Claims Act (31 U.S.C., Chp. 37)

This statute is used to prosecute, civilly, those professionals in occupational therapy offices who purposefully submit fraudulent or false claims to insurance companies in order to receive a payment.

For example, if a gastroenterologist bills a patient’s insurance company for an endoscopic exam that was never actually provided to that patient, that physician may be charged with fraud under the False Claims Act. 

If you are found guilty of a violation of the False Claims Act, you could face a fine of between $5,000 to $10,000. 

In addition, you can be ordered to pay up to 3 times the amount that the government was defrauded of as a result of the scheme. 

The Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b))

This statute looks to punish the purposeful payment made in order to reward people or companies for patient referrals or the generation of business involving any item or service payable by the federal health care programs, including Medicare and Medicaid. 

For example, if an orthopedic surgeon pays a general practitioner to refer, specifically, patients with Medicare to come to the surgeon’s office. This would be a violation of the Anti-Kickback Statute.   

If you are found guilty of violating the Anti-Kickback statute you face fines of up to $25,000, a prison sentence of up to 5 years, or a combination of both.

The Physician Self-Referral Law (42 U.S.C. § 1395nn)

The Physician Self-Referral Law, also known as Stark Law, is aimed at punishing those doctors who refer patients to receive specialized medical care from any facility or business that the doctor, or any member of the doctor’s immediate family, has some financial interest in. 

For example, if a general practitioner, after seeing a patient, recommends that they need some type of imaging service, like a CAT scan and refers them to an imaging center.

If the physician refers the patient to an imaging center that the physician’s daughter owns, that referral would be a violation of the Stark law. 

Other statutes that if violated would be considered health care fraud includes the Exclusion Statute (42 U.S.C. § 1320a-7).

Health Care Fraud Investigations

Due to the costly effects of health care fraud, varying government investigative agencies have begun cracking down on those who are alleged to have committed some type of health care fraud.   

These agencies include the FBI, the Department of Justice (DOJ), the Office of the Inspector General (OIG), and the Office of Health and Human Services (HHS).

Health Care Fraud and Physicians in the News

Health care fraud can be the product of various different schemes, or plans. 

Below are some of the most popular health care fraud schemes for which physicians have been investigated, charged, plead guilty to, or sentenced for. 

Prescribing Unnecessary Medical Treatment

Physician Pleads Guilty for Role in Detroit-Area Medicare Fraud Scheme

In July 2014, Walayat Khan, a Detroit-area physician, pleaded guilty to his role in a $7 million health care scheme. 

Starting in January 2009, Dr. Khan and his co-conspirators, began referring patients with Medicare benefits to a home health aide service. The services were not needed by the patients, and Dr. Khan stated that he knew this. 

In addition, Dr. Khan would sign off on falsified documents about at-home treatments and services, like physical therapy, that were also unnecessary and often not provided. 

Further, Dr. Khan accepted kickbacks and cash for his referrals. Dr. Kahn also paid kickbacks to another physician so that that physician would falsify records. 

With Dr. Kahn’s assistance, the scheme was able to defraud Medicare of over $5.5 million dollars. 

For more information and for the full DOJ press release, click this link or copy and paste the URL below.

https://www.justice.gov/opa/pr/physician-pleads-guilty-role-detroit-area-medicare-fraud-scheme-1