The False Claims Act and Chiropractic Physicians
Health care fraud is a serious problem. It is estimated that fraud, waste, and abuse cost taxpayers $30 to $100 billion dollars each year. Aside from money lost, patients may be exposed to unnecessary services, and money is no longer available for legitimate care for others.
- Fraud is obtaining something of value through intentional misrepresentation or concealment of material facts.
- Waste is incurring unnecessary costs as a result of deficient management, systems, or controls.
- Abuse is excessively or improperly using government resources for things like unnecessary care or having excessive prices.
Examples: Billing for a Chiropractic Manipulative Treatment when the patient wasn’t even in the office that day, or billing Medicare for maintenance visits as if they are active care.
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The government has asked health care providers, and their staff, to partner in preventing fraud, waste, and abuse. The False Claims Act makes it illegal to submit false or fraudulent claims for payment to Medicare or Medicaid. A claim would be considered false if the service is not actually rendered, or was already paid, miscoded, or not supported by the record. For violations, the fine is up to three times the amount lost, plus $11,000 per claim, so it adds up quickly. (See 31 U.S.C. §§ 3729–3733).
The way this rule is written, it doesn’t matter if you intended to defraud the government. If you hide your head in the sand and complain that you just didn’t know the rules, you are still liable. Also, there is a whistleblower provision so that anyone can report a violation and be entitled to a portion of the recovery money. And this is all just the civil part of this law. There are criminal penalties too, which include more fines and imprisonment.
The United States filed a False Claims Act complaint in 2022 against a chiropractor associated with several labs set up for treatment of peripheral arterial disease. The complaint alleges that from at least Jan. 1, 2018, through June 30, 2022, the chiropractor and the defendants representing the lab offered physicians the opportunity to invest in the office-based labs to induce the physicians to refer their Medicare and TRICARE patients. This issue fell under the jurisdiction of the US Department of Justice and the FBI.
If all this doesn’t motivate you to look closer at this law, then you ought to know that the Office of the Inspector General (OIG) has laid out guidelines that state that you need to have explicitly documented policies and procedures in place to make sure your clinic is compliant with the False Claims Act. What can you do to show you are a good, law-abiding chiropractic physician?
- Conduct and document regular billing and coding reviews. A consultant can be hired to do this, or it can be done internally, but it needs to be documented.
- If a mistake is found, pay the money back within 60 days.
Every office should have an “OIG Compliance Manual” that has action steps written into the Policies and Procedures section. But that is only the first step. The second is that providers must actually do what they write about in their manual. It is not that hard to stay compliant with the False Claims Act, and it can save the clinic money by avoiding the consequences of a mistake. (See the Office of Inspector General’s (OIG) General Compliance Program Guidance (GCPG), published November 2023)
Note: This article is Part 1 of 5: Compliance Laws Every Chiropractic Physician Should Know
- Part 1: The False Claims Act for Chiropractic Physicians
- Part 2: Anti-Kickback Statute for Chiropractic Physicians
- Part 3: Self-Referral Law for Chiropractic Physicians
- Part 4: Exclusion Authority Requirements for Chiropractic Practices
- Part 5: Civil Monetary Penalties, OIG, and the Chiropractic Practice
