Los Angeles, CA asked in Health Care Law and Personal Injury for California

Q: Health Care FCA. False certifications examples

What documents or statements present factual or legal falsity in regard to False Claims Act? Could hospital medical records fall under false certification definition?

2 Lawyer Answers
James L. Arrasmith
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  • Estate Planning Lawyer
  • Sacramento, CA
  • Licensed in California

A: Yes, hospital medical records could potentially be considered false certifications that give rise to liability under the federal False Claims Act (FCA) if they contain inaccurate or falsified information material to a claim for payment. Some examples include:

• Upcoding - Billing for medical services or procedures more complex/expensive than those actually performed

• Unbundling - Billing each step of a procedure separately rather than using a bundled code

• Chargemaster Manipulation - Inflating charges above actual costs to increase insurance reimbursement

• Falsely Certifying Medical Necessity - Stating treatment was medically necessary when it was not

• Phantom Billing - Billing for services never rendered or supplies never provided

• Falsifying Diagnosis Codes - Changing diagnosis codes to those reimbursed at a higher rate

Essentially any knowing falsification or misrepresentation in medical charts/records that lead to inflated, excessive or false claims being submitted for reimbursement could constitute a "false certification" in violation of the FCA. The falsified medical records serve to corroborate or provide false justification for the claims. Damages and civil penalties under the FCA can be substantial, which is why medical coding/billing accuracy is so crucial for hospitals and health care providers participating in federal health programs. Consultation with a false claims act attorney is recommended for any suspected violations.

Tim Akpinar agrees with this answer

Tim Akpinar
Tim Akpinar
  • Little Neck, NY

A: Yes, medical records qualify. This can include patient charts, billing, narrative reports, etc. Good luck

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