False Claims Act

The False Claims Act prohibits knowingly presenting (or causing to be presented) to the federal government a false or fraudulent claim for payment or approval. When submitting claims data to CMS for payment, CareFirst Medicare Advantage and our subcontractors must certify that claims data is true and accurate to the best of their knowledge and belief.

The False Claims Act is enforced against any individual/entity that knowingly submits (or causes another individual/entity to submit) a false claim for payment to the Federal government.

Note: Intent to defraud is not necessary to prove that the government was in fact defrauded, so long as it is established that the person acted “with intent to defraud.”

Anti-Kickback Statute

Section 1128B9b of the Social Security Act (42 U.S.C. 1320a-7b(b)) provides criminal penalties for individuals and entities that knowingly and willfully offer, pay, solicit, or receive remuneration in order to induce or reward business payable (or reimbursable) under the Medicare or other Federal health care programs.

For example, recent kickback cases have involved unlawful referral payments in form of free office space, free equipment, free drugs or supplies, inflated or sham consulting contracts, and travel and entertainment to physicians by hospitals, pharmaceutical companies and laboratories.

In addition to applicable criminal sanctions, an individual or entity may be excluded from participation in the Medicare and other Federal health care programs and subject to civil monetary penalties. For purposes of the anti-kickback statute, “remuneration” includes the transfer of anything of value, directly or indirectly, overtly or covertly, in cash or in kind.                                                

HIPAA

Among other things, the Health Insurance Portability and Accountability Act (HIPAA), was enacted for the purpose of improving the efficiency and effectiveness of health information systems through the establishment of standards and requirements for the electronic transmission of certain health information. This purpose has been effectuated through the promulgation of various regulations including those establishing standards for certain electronic transactions, minimum security requirements, and minimum privacy protections for individually identifiable health information that is held by covered entities (i.e., protected health information). Additional rules have or will establish national identifiers under HIPAA for providers, plans and employers. Covered entities include health plans, health care clearing houses and certain health care providers (namely those that conduct covered transactions).