Overpayment or reverse false claim? How to recognize the difference

Listen to article
16 minute read

Healthcare compliance is anything but straightforward. There are hundreds of national coverage determinations and over a thousand local coverage determinations that cross jurisdictions and topics, and those determinations are at times less than clear. There are statutes, regulations, and advisory opinions that approve of some financial relationships impacting healthcare and disapprove of others but also stay silent as to a host of issues that affect the modern practice of medicine. And not to mention, circuit splits galore. The healthcare compliance landscape shifts constantly, like tectonic plates set atop the spinning teacups at Disney World.

Sitting in those teacups, mistakes happen. Healthcare providers make claims to federal payers that are later called into question by learning additional facts or legal requirements. When those situations arise, at what point does overpayment arise? And, most critically, at what point does an overpayment become a violation of the reverse false claim prong of the False Claims Act (FCA)?

Everyone in healthcare compliance needs to know where that line is because crossing it creates a world of treble damages, civil penalties, and whistleblowers.

But, unfortunately for everyone, that line is less than crystal clear. This article attempts to clarify the line as best we can, given the current legal landscape and offers some advice on what to do when you find yourself close to the line.

Because the teacups will continue to spin.

This document is only available to members. Please log in or become a member.

Would you like to read this entire article?

If you already subscribe to this publication, just log in. If not, let us send you an email with a link that will allow you to read the entire article for free. Just complete the following form.

* required field