Knowledge under the FCA is defined as actual knowledge, reckless disregard, or intentional indifference to the law.
A version of this article was first published November 9, 2020, by HCPro's Revenue Cycle Advisor, a sibling publication to HealthLeaders.
Q: For the purposes of determining a Medicare overpayment, should claims that we are uncertain whether they were appropriate be included? Is this defined under the False Claims Act (FCA)?
A: Given the complexity of Medicare rules and regulations, there may be good-faith uncertainty over the appropriateness of certain claims and, thus, whether there is a known overpayment.
Providers need to analyze the issues surrounding alleged overpayments to determine whether the amount received can be clearly determined to have been paid in error.
Knowledge under the FCA is defined as actual knowledge, reckless disregard, or intentional indifference to the law.
Thus, not auditing billing systems and protocol, or not reviewing financial arrangements for Stark Law compliance, can generate “known” overpayments due to the reckless disregard or intentional indifference standards under the FCA.
For more information, see The Compliance Officer’s Handbook, Fourth Edition.
Revenue Cycle Advisor combines all of HCPro's Medicare regulatory and reimbursement resources into one handy and easy-to-access portal. News is not just repeated from other sources. It is analyzed by our Medicare experts so professionals can comprehend any new rule and regulatory updates thoroughly. Learn more.