3 fraud and abuse laws every physician should know

On Behalf of | Apr 27, 2024 | Fraud

Physicians are regarded as being trustworthy and caring. In the highly regulated healthcare field, they understand that their practices should align with state and federal laws concerning fraud and abuse.

Non-compliance with these regulations can result in severe consequences, ranging from substantial fines to losing their medical license. However, understanding and complying with these laws is not just about avoiding penalties; it’s about integrity and patient trust. Here are some fundamental laws every California physician should be familiar with:

1. False Claims Act (FCA)

Healthcare providers need to maintain accurate and honest billing records. The FCA imposes liability on anyone who defrauds governmental programs, such as:

  • Submitting claims for services not rendered
  • Upcoding
  • Split billing
  • Billing for unnecessary procedures

2. Anti-Kickback Statute (AKS)

The AKS prohibits the exchange (or an offer to exchange) of anything of value to receive the referral of any federal healthcare program business. This includes referrals for services or items covered by programs like Medicare and Medicaid. Physicians must carefully review their relationships with vendors, other physicians or entities to which they refer patients, ensuring that no part of their compensation arrangements violates this statute.

3. Stark Law

This law prohibits physicians from referring patients to receive “designated health services” payable by Medicare or Medicaid from entities with which the physician or an immediate family member is benefiting financially.

In addition to federal laws, California has its own regulations to prevent healthcare fraud. The California Insurance Frauds Prevention Act (IFPA) allows whistleblowers to bring action against healthcare providers who commit fraud against private insurers. California Welfare and Institutions Code Section 14107 is designed to combat Medi-Cal fraud and abuse.

Accusations of healthcare fraud and abuse can cost a physician both financially and professionally. Your best option for a favorable outcome is to work with someone who can review your case and present a strategic defense.

FindLaw Network
Gary Jay Kaufman
"" ""