Civil and criminal penalties increased for fraud and abuse

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The Bipartisan Budget Act of 2018 (BBA 2018) significantly increased civil and criminal penalties for federal health care program fraud and abuse. Below is a summary of some of the BBA 2018 changes to the maximum penalty amounts, which apply for acts committed after February 9, 2018.

Civil Monetary Penalties

  • $5,000
    • A hospital or physician that gives or receives a payment to reduce/limit medically necessary services to Medicare/Medicaid beneficiaries
  • $10,000
    • A physician who signs a home health certification knowing all the requirements are not met
  • $20,000
    • False claims
    • Requesting payment in violation of assignment agreement
    • Excluded party retaining ownership/controlling interest in a participating entity (per day)
    • Beneficiary inducements
    • Employing/contracting with an excluded individual
    • Ordering/prescribing while excluded
    • Failure to report and return an overpayment
  • $30,000
    • Giving/causing to be presented false or misleading information to influence a hospital discharge decision
    • Failure to grant timely access to OIG (per day)
  • $100,000
    • Violating the Anti-Kickback Statute
    • Making/causing to be made false statements, omission or misrepresentation of a material fact in an application, bid or contract to participate/enroll as a provider/supplier

Criminal Penalties

  • $100,000 plus 10 years imprisonment (a felony) for persons who commit any of the acts listed below in connection with the furnishing of items/services reimbursable by federal health care programs:
    • Violating the Anti-Kickback Statute
    • Making/causing to be made a false statement or representation of a material fact:
      • In an application for or payment under a federal health care program
      • For use in determining rights to such payment
    • Concealing/failing to disclose knowledge of the occurrence of an event affecting the initial/continuing right to any payment with an intent to fraudulently secure such payment
    • Presenting/causing to be presented a claim for a physician service knowing the individual is not a licensed physician
  • $20,000 plus one year imprisonment (a misdemeanor) for the same offenses listed above where the conduct is by the same person who furnishes the items/services payable under federal health care programs
  • $4,000 plus imprisonment of up to six months (misdemeanor)
    • Repeatedly violating the terms of the assignment agreement

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