Introduction Healthcare organizations

Introduction Healthcare organizations
Sample Answer for Introduction Healthcare organizations Included After Question

Introduction Healthcare organizations

Develop Code of Ethics with the intention of providing its members with a model for how they should behave themselves. It provides guidelines for ethical conduct that healthcare leaders should follow in their interactions with other professionals (Rippen & Risk, 2000).

A Sample Answer For the Assignment: Introduction Healthcare organizations
Title: Introduction Healthcare organizations

The name of my organization is Bezos Community Medical Center in Texas. This is a non-profit organization which will connect about 28 hospitals and serve lowincome people. At the Bezos Community Medical Center, patients can access various medical services, including hospice care, hospital, emergency care, primary care, home care, labs, outpatient surgery, pharmacies, and rehabilitation programs. Organizational Policies and Procedures (Corporate Compliance Program) • All employees and executives shall uphold values, mission, and code of ethics Bezos Community Medical Center. • As far as statutory compliance goes, all employees and healthcare executives should obey all local, state and federal laws including the Texas Education Code and Texas Penal Code. An employee who disrupts any public service, disciplinary, administrative, research, educational, and teaching activities will be subject to a disciplinary action including firing. • Any comments regarding the management of the healthcare facility in whole or in part, must be reviewed by the Board of Trustees before being communicated to the Senate or any relevant Government entity or personnel. • All employees should also observe the following policies; o Harassment and anti-discriminatory policy o Health and safety policy o Use of alcohol and drugs policy o Non-smoking policy o Mobile phone usage policy o Email and internet policy o Recruitment policy ▪ All these policies can be found in the corporate compliance policies section of the organization’s handbook. Organizational Code of Ethical Conduct • Responsibilities for healthcare executives and employees in leadership: o Upholding the Code of Ethics o Observing vision and mission of the organization o Laws compliance o They should conduct all their activities with good faith, fairness, respect, integrity, and honesty. • Responsibilities for healthcare executives and employees in serving patients (customer service): o All healthcare executives should work within the scope of their authority to build a rapport with patients, foster a culture of dignity and respect, and avoid any misuse of power. o They should also safeguard the privacy and confidentiality of every patient. o Avoid abuse of power o Foster equitability and fairness among patient’s payment processes o Follow a set of standard procedures when solving problems and making decisions • Healthcare executives should create a workplace free from any coercion to perform unethical or illegal acts. • They should also create a workplace should be free of any sexual harassment. • They should also create an equitable, healthy, and safe workplace. Foster a culture of inclusivity. • Healthcare executives and employees partner with the community to meet their health needs. • All stakeholders involved should lead Bezos Community Medical Center to prioritize patient care. References ACHE Code of Ethics. Retrieved from; https://www.ache.org/about-ache/our-story/ourcommitments/ethics/ache-code-of-ethics Rippen, H., & Risk, A. (2000). e-Health code of ethics (May 24). Journal of medical internet research, 2(2), e9. CHAPTER FRAUD LAWS AND CORPORATE COMPLIANCE 15 Copyright 2020. Health Administration Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. After reading this chapter, you will • understand the basic federal laws relating to healthcare fraud and abuse and how the Affordable Care Act has affected them, • be able to identify the most significant statutes relating to fraud and abuse in federal healthcare payment programs, • know how the concepts of kickback and self-referral affect hospital operations, and • recognize the benefits of maintaining an active corporate integrity program. A s we all know, healthcare is a multitrillion-dollar industry, and it grows every year. According to the Centers for Medicare & Medicaid Services    (CMS), total national health expenditures were $3.5 trillion in 2017— nearly 18 percent of our gross domestic product. Under current law, this spending is projected to grow at an average rate of 5.5 percent per year and reach nearly $6.0 trillion by 2027.1 Given the astronomical dollar sums involved, it is no wonder that this sector of the economy is a prime target for malefactors who want to defraud the government and health insurance companies. This chapter discusses the most significant laws aimed at curbing healthcare fraud, and it gives examples of how those laws are enforced. The chapter also explores briefly the Foreign Corrupt Practices Act (FCPA), a statute intended to prevent bribery of foreign officials for business purposes and which has become more significant for healthcare because of medical tourism and international commerce. The chapter concludes with a review of corporate integrity programs; that is, efforts to promote legal compliance and business ethics. Upright organizations must be sensitive to the potential for their employees to be involved in fraud, abuse, and other illicit conduct. They must work to maintain high ethical principles not only because an image of moral respectability is good for business but also because such conduct is simply the right thing to do. 567 Copying and distribution of this PDF is prohibited without written permission. EBSCO Publishing : eBook Collection (EBSCOhost) – printed on 1/4/2023 1:56 PM via TRIDENT UNIVERSITY For permission, please contact Copyright Clearance Center at www.copyright.com AN: 2361947 ; Stuart Showalter.; The Law of Healthcare Administration, Ninth Edition Account: s3642728.main.ehost 568 T h e Law of H e a l th c a re Ad mi n i stra ti o n The Enforcement Climate “Follow the money” is an oft-heard catchphrase used in the context of corruption scandals, but it could also be the mantra of those who commit healthcare fraud: they wish to follow the money to its source, which in large measure is government health programs. For example, in 2017 Medicare spending totaled $705.9 billion and Medicaid spending was $581.9 billion. These numbers are expected to continue to rise due to the aging of the population, increased demand for treatment of chronic diseases, and the high cost of new drugs and technology. The government is an obvious target for fraud because of these numbers, and elimination of fraud is therefore a high priority for law enforcement and policymakers. Each year, more resources are allocated to the Department of Justice (DOJ), the Federal Bureau of Investigation, the Offices of the United States Attorneys, the Department of Health and Human Services (HHS) Office of Inspector General, and other enforcement agencies. State attorneys general conduct their own investigations and prosecutions, often working closely with federal officials. Private individuals who have firsthand knowledge of fraud are permitted to sue on behalf of the government and to collect a percentage of any proceeds recovered. The Affordable Care Act (ACA) placed additional emphasis on fraud prevention by adding numerous provisions aimed at enhancing the integrity of government programs, including a title of more than a hundred legislative pages under the heading “Transparency and Program Integrity.” The impact of this legislation is considered in the ensuing discussion. The most significant changes affect the False Claims Act (FCA), the antikickback statute, and the Stark physician self-referral law, about which more later. Settlements Can Be Huge Verdicts and settlements in civil fraud cases can amount to tens or even hundreds of millions of dollars (see exhibit 15.1), and offenders convicted of criminal offenses can receive massive fines and lengthy jail terms. In United States v. Lorenzo, for example, a dentist billed Medicare for “consultations” on nursing home residents. Medicare does not cover dental services, and Dr. Lorenzo’s examinations, according to the court, “were nothing more than the oral cancer screening that previously had been done as part of a routine dental examination. None of these examinations had been conducted at the request of an attending physician or because of a specifically identified medical concern.”2 The government proved that Dr. Lorenzo had submitted 3,683 false claims and, as a result, had received overpayments totaling $130,719.20. The court assessed damages of approximately $19 million, nearly 150 times the amount of the fraud. Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com EBSCOhost – printed on 1/4/2023 1:56 PM via TRIDENT UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use C h a p te r 15: Fraud L aws and C or p orate C om p lianc e Defendant’s Name Allegation Settlement AmerisourceBergen Corp. Drug repackaging $625 million Actelion Pharmaceuticals US, Inc. Kickbacks (illegally paying copays) $360 million A subsidiary of DaVita, Inc. False billing $270 million Health Management Associates Kickbacks; false claims $260 million William Beaumont Hosp., Detroit Kickback $84.5 million Source: John Commins, Top 5 Healthcare Sector Fraud Settlements for 2018, Health Leaders (published December 26, 2018), at https://www.healthleadersmedia.com/top-5-healthcaresector-fraud-settlements-2018. A second example involved Dr. Krizek, a psychiatrist trained at the Charles University in Prague (former Czechoslovakia) and Beth Israel Hospital in New York City. Dr. Krizek had been practicing in Washington, DC, for 21 years when the government brought a false claims case against him. According to the court, Dr. Krizek was a “capable and competent physician,” many of whose patients suffered from “horribly severe psychiatric disorders and often suffered simultaneously from other serious medical conditions.”3 The prosecution could not prove that Dr. Krizek rendered inappropriate care, but numerous false claims allegations were his downfall. The evidence showed that the doctor charged the government for a full face-to-face session—45 to 50 minutes—regardless of whether he spent 20 minutes or two hours with a patient. He argued that even if he spent only half an hour with the patient in person, he considered related services—such as medication management and discussions with other staff—to be part of patient care and therefore thought he had not harmed the government. One piece of evidence showed that his practice submitted 23 claims for full sessions in a single day, so the court was impressed with neither Dr. Krizek’s argument nor his management skills: “While Dr. Krizek was a dedicated and competent doctor . . . his billing practices, or at a minimum his oversight of [the] billing system, was seriously deficient. Dr. Krizek knew little or nothing of the details of how the bills were submitted [on his behalf].”4 The court concluded that Dr. Krizek must be held accountable for his billing system along with those who carried it out. . . . The Court . . . will hold the defendants liable under the False Claims Act on those days where claims were submitted in excess of the equivalent of twelve . . . claims (nine patient-treatment hours) in a single day and where Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com EBSCOhost – printed on 1/4/2023 1:56 PM via TRIDENT UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use 569 EXHIBIT 15.1 Top Five Healthcare Fraud Settlements of 2018 570 T h e Law of H e a l th c a re Ad mi n i stra ti o n the defendants cannot establish that Dr. Krizek legitimately devoted the claimed amount of time to patient care on the day in question.5 Among the many interesting aspects of the various Krizek court opinions (four in all), perhaps the most noteworthy is the trial court’s displeasure with how the government handled the case. After more than four years of litigation, the judge slammed the door in 1998 with this parting shot: The Government insists on pursuing a case that should long have been over. If the Court acceded to all of the Government’s requests, this litigation would proceed well into the next century. The Government has won its case and gained a substantial recovery. Dr. Krizek is now retired and is no longer practicing psychiatry. Although apparently a fine physician, he is now a broken man. Not only is he out of the medical profession, but also he is suffering from the advanced stages of cancer. The Government refuses to let go of this case. When it began its case, the Government was seeking over $80 million worth of damages, a figure that the Court of Appeals declared was “astronomical.” Despite the fact that Dr. Krizek is incapable of paying such a sum, the Government continues to relentlessly pursue Dr. Krizek, who is at this point a broken and sick man. The Government’s pursuit of Dr. Krizek is reminiscent of Inspector Javert’s quest to capture Jean Valjean in Victor Hugo’s Les Miserables. While the Government’s vigor in pursuing violators of the law is to be commended, there comes a point when a civilized society must say enough is enough. That point has been reached in this case.6 Notwithstanding the overly zealous prosecution of Dr. Krizek, his and other cases demonstrate the seriousness with which the government views fraud and abuse. Under the joint direction of the attorney general and the secretary of HHS, the federal Health Care Fraud and Abuse Control Program recovers more than $8 for every $1 spent on its investigations and returns more than $4 billion dollars to the US Treasury every year.7 As these statistics show, prevention of fraud and abuse should be a top priority for healthcare administration, and a basic understanding of the major criminal and civil fraud statutes is therefore essential. The following are some of the most obvious types of healthcare fraud and abuse: • Filing claims for services not rendered or not medically necessary • Misrepresenting the time, location, frequency, duration, or provider of services • Assigning a higher payment than the procedure or diagnosis warrants (upcoding) • Billing a battery of services (e.g., laboratory tests) separately (unbundling) Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com EBSCOhost – printed on 1/4/2023 1:56 PM via TRIDENT UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use C h a p te r 15: Fraud L aws and C or p orate C om p lianc e • Violating the “three-day rule,” which states that outpatient diagnostic procedures performed on any of the three days before hospitalization are deemed part of the Medicare diagnosis-related group payment and are not to be billed separately • Paying kickbacks to induce referrals or the purchase of goods or services • Billing for services said to have been “incident to” a physician’s services but that were not provided under the physician’s direct supervision • Referring patients to entities in which the physician has a financial interest (self-referral) The major statutes that these kinds of activities may violate include the civil and criminal FCA, the antikickback law, and the physician self-referral statute (known as the Stark law). Depending on the facts of the case, other statutes that may be implicated include mail fraud and wire fraud statutes; the Racketeer Influenced and Corrupt Organizations Act; money-laundering statutes; the FCPA; and various criminal statutes relating to theft, embezzlement, bribery, conspiracy, and obstruction of justice. Whereas this chapter focuses on the major healthcare fraud statutes and does not address violations of the other laws mentioned, myriad legal standards (both state and federal) apply to healthcare organizations, and the importance of competent legal counsel and a process for preventing criminal activity cannot be overemphasized. Federal False Claims Act The federal government’s main weapon in the so-called war on fraud and abuse is the FCA,8 which provides that a person is liable for penalties if he • “knowingly presents, or causes to be presented, to an officer or employee of the United States . . . a false or fraudulent claim for payment or approval”; • “knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the Government”; • “conspires to defraud the Government by getting a false or fraudulent claim allowed or paid”; or • “knowingly makes, uses, or causes to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the government.” (This provision was added in 1986 to deal with reverse false claims—attempts to avoid paying money owed to the government.) Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com EBSCOhost – printed on 1/4/2023 1:56 PM via TRIDENT UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use 571 572 T h e Law of H e a l th c a re Ad mi n i stra ti o n scienter Knowledge by a defendant that their acts were illegal or their statements were fraudulent. Civil penalties under the federal law can be as much as $11,000 per claim plus three times the amount of damages sustained by the government. (The statute sets a penalty range of $5,000 to $10,000 per claim, but it also allows for periodic adjustments. As of 2019 the amounts were $5,500 to $11,000.) In addition, the costs of the prosecution are charged to the defendant. If the claim is found to be false, penalties and costs may be assessed even if the claim was not paid and the government suffered no damages.9 Interestingly, the FCA was enacted during the Civil War to stem the practice of overcharging the Union Army for goods and services. Apparently the term claim was better understood then than it is now because it is not defined in the statute. In healthcare, the definition of “claim” has been a matter of some dispute. For example, each procedure code on a billing form could be considered a separate claim. Therefore, up to $10,000 in penalties could be assessed for each false code. By this line of reasoning, as much as $200,000 plus damages and court costs could be assessed for 20 false codes. The definition of “claim” was addressed in the appeal of Krizek, in which the court of appeals held that each billing form was one claim, irrespective of the number of false codes it contained. The court asserted that the form was merely one request for payment of the total sum it represented.10 This definition seems logical and is consistent with other cases defining a claim as “a demand for money or for some transfer of public property.”11 Another interesting question is that of scienter: Did the defendant deliberately and willfully break the law? Or, in the words of the FCA, did the defendant do so “knowingly”? First-year law students are painfully aware of the Socratic dialogue that could attend the definition of knowingly. For example, consider the following conversation: Professor Kingsfield. Mr. Showalter, what if I sign a claim form, put it in a stamped envelope, and mail it to Medicare? Have I knowingly submitted that claim? Student Showalter. I guess so. Unless you were drunk or mentally incompetent, you knew what you were doing. You were mailing a claim form and expecting to get paid. Kingsfield. How much did I expect to get paid? Showalter. Whatever amount is on the form. Kingsfield. What if I didn’t look at the amount but just signed a bunch of forms my staff gave me at the end of the day and those forms had errors on them? Showalter. Well . . . [shifting in his seat and beginning to sweat] Kingsfield. Well, what? Are the forms that have errors on them false claims? Showalter. Well, they’re erroneous. But if you didn’t know they had errors and just assumed that your staff were doing their jobs correctly . . . Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com EBSCOhost – printed on 1/4/2023 1:56 PM via TRIDENT UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use C h a p te r 15: Fraud L aws and C or p orate C om p lianc e Kingsfield. Assumed? Never assume anything in this class or any legal matter! Showalter. Sorry. Kingsfield. Let’s consider another case. Suppose that I know my claims contain the occasional error—some are over, some are under—but I think they will all balance out in the end, sort of the “no harm, no foul” approach to billing. And suppose I think that the False Claims Act applies only to overbilling the government on purpose, which I haven’t done. What say you now? Showalter. Hmm. You knew you were submitting a bill, but you didn’t know that the particular bill was wrong, and you didn’t know that submitting incorrect bills is illegal when you should have had a system in place to check them for errors. Good question! So goes this uncomfortable exchange for a few more minutes. In 1986, Congress addressed the issue of scienter by amending the FCA to say that “no proof of specific intent to defraud” is required. Instead, the person must either (1) have actual knowledge that the information is false, (2) act in deliberate ignorance of the truth or falsity of the information, or (3) act with reckless disregard of whether it is true or false.12 As stated in the committee report accompanying the 1986 amendment, The Committee is firm in its intentions that the act not punish honest mistakes or incorrect claims submitted through mere negligence. But the Committee does believe the civil False Claims Act should recognize that those doing business with the Government have an obligation to make a limited inquiry to ensure the claims they submit are accurate.13 The Krizek case (discussed earlier) shows how this standard is used. Although Dr. Krizek was not personally involved in the billing process, the court found that he and the other defendants had submitted the claims knowingly: “These were not ‘mistakes’ [or] merely negligent conduct. Under the statutory definition of ‘knowing’ conduct, the court is compelled to conclude that the defendants acted with reckless disregard as to the truth or falsity of the submissions” [italics added].14 This standard requires healthcare providers—and their top management and governing board members—to have mechanisms in place to verify the accuracy of their organization’s claims. A further incentive to comply is the threat of exclusion from participation in Medicare and Medicaid because the government may exclude from participation any individual who (1) has a direct or indirect ownership or control interest in a sanctioned entity and has acted in “deliberate ignorance” of the information, or (2) is an officer or a managing employee of a convicted or excluded entity, irrespective of whether the individual participated in the offense.15 Any excluded person who retains ownership or control or who continues to serve as an officer or a managing Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com EBSCOhost – printed on 1/4/2023 1:56 PM via TRIDENT UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use 573 574 T h e Law of H e a l th c a re Ad mi n i stra ti o n employee in such entity may be fined $20,000 for each day the relationship continues.16 This threat and the potential for criminal convictions and massive fines have been the major forces motivating healthcare organizations to adopt corporate compliance programs (discussed later in this chapter). FCA cases are usually investigated by the Office of Inspector General and brought by a US attorney or the DOJ. An unusual feature of the statute, however, allows private citizens to sue on their own behalf and, as stated earlier, on behalf of the government to recover damages and penalties. These qui tam (whistle-blower) lawsuits have become an important factor in FCA enforcement because, if successful, the plaintiff (a relator in legal parlance) can share in the amount of the award (see exhibit 15.3 and Legal Brief). It must be noted that at least 31 states also have false claims statutes that authorize qui tam whistle-blowers to file suit. These laws are a separate basis for liability, independent of the federal FCA, and they can be used for recovery in cases of Medicaid and other fraud. The standards and defenses under state law differ from those under the federal statute. Any person with information about healthcare fraud can be a whistleblower. Person is defined as “any natural person, partnership, corporation, association, or other legal entity, including any State or political subdivision of a State.”17 The relator must file the complaint, which is immediately sealed and thus not made public pending an investigation, and file a copy with the US attorney general and the appropriate US attorney. The government then has 60 days, plus extensions for good cause, to determine whether to pursue the case. If the government decides to take over the case, the relator will receive 15–25 percent of the amount recovered. If the government declines, the relator may still pursue the matter and, if successful, will receive up to 30 percent of the recovery. To file suit, the potential qui tam plaintiff and the allegations must meet certain conditions. Substantially, the same Legal Brief allegations or transactions must not have been disclosed publicly at an earlier date— unless the qui tam plaintiff is the original Qui tam (“he who”) is shorthand for a Latin phrase source of the previously disclosed informathat means “he who sues for the king as well as for tion. Original source means someone who himself.” In such a case, the plaintiff (relator) files suit as a kind of private attorney general on behalf gave the government the information in of the government. The government can choose to the first place or who has information additake over the prosecution, but if it declines to do tional to that previously disclosed.18 If the so the relator can proceed alone. jurisdictional barriers are met and the facts Federal qui tam cases are cited as United of the case warrant recovery, the qui tam States ex rel. [name] v. [name of defendant]. Ex rel. plaintiff can proceed to assist the governmeans “by the relation of ” (or, more loosely, “at the request of ”) and indicates the name of the relator. ment or pursue the case individually, often to significant financial advantage. Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com EBSCOhost – printed on 1/4/2023 1:56 PM via TRIDENT UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use C h a p te r 15: Fraud L aws and C or p orate C om p lianc e Federal law provides a remedy for whistle-blowers who are discharged, demoted, harassed, or otherwise discriminated against because they filed a qui tam case.19 Given the financial incentives and the protection against employment-related retaliation, the qui tam lawsuit has become a commonly used and effective means of combating fraud and abuse. Occasionally, qui tam plaintiffs in healthcare cases argue that a claim involving a kickback or an illegal physician self-referral (described in more detail in the following sections) violates the FCA, even though the claim is otherwise legitimate.20 For example, in United States ex rel. Woodard v. Country View Care Center, Inc.,21 the defendants had submitted Medicare cost reports that included among their expenses some payments to “consultants” that were actually kickbacks for referrals. Because the defendants’ reimbursement was based on the cost reports, the court held that the FCA applied. United States v. Kensington Hospital,22 filed after the advent of the prospective payment system, brought a new twist to the argument. The defendants asserted that because their Medicaid reimbursement was a set amount, the government could not have suffered a loss and the cost of the kickbacks did not make the claims false. Citing United States ex rel. Marcus v. Hess and other cases, the court disagreed, holding that the government was not required to show actual damages to prove an FCA violation. In neither Country View nor Kensington Hospital did the plaintiffs specifically base their claim of FCA liability on the antikickback or self-referral statutes. Some subsequent cases did so, however, and they have survived scrutiny by the courts. For example, in United States ex rel. Pogue v. American Healthcorp,23 a trial court refused to dismiss an FCA case based on violations of the antikickback and the Stark self-referral laws. The court agreed with the relator’s contention that “participation in any federal program involves an implied certification [emphasis added] that the participant will abide by and adhere to all statutes, rules, and regulations governing that program.”24 It held, in effect, that Stark violations create prohibited financial relationships that taint the Medicare claims and that the FCA therefore applies. In 2016, the US Supreme Court held the implied certification rationale to be valid in certain circumstances, and the theory has been followed in some cases and questioned in others.25 Thus, though the concept that an FCA case can be based on violation of the antikickback or self-referral laws appears to be consistent with the 1986 amendments, it remains to be seen in what situations it will be applied. In addition, the ACA codifies the implied certification rationale, at least insofar as the antikickback statute is concerned. The ACA states that “a claim that includes items or services resulting from a violation of the [antikickback statute] constitutes a false or fraudulent claim for purposes of [the civil False Claims Act].”26 Thus, compliance with the antikickback statute is a precondition for payment, and noncompliance with the antikickback statute Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com EBSCOhost – printed on 1/4/2023 1:56 PM via TRIDENT UNIVERSITY. All use subject to https://www.ebsco.com/terms-of-use 575 576 T h e Law of H e a l th c a re Ad mi n i stra ti o n Legal Brief When the government wants to make regulatory compliance a precondition for payment, it certainly knows how to do so. The Medicare claim form (CMS-1500) states in boldface: “Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties.” It also includes the following language: NOTICE: This is to certify that the foregoing information is true, accurate and complete. I understand that payment and satisfaction of this claim will be from Federal and State funds, and that any false claims, statements, or documents, or concealment of a material fact, may be prosecuted under applicable Federal or State laws. This notice appears to turn what would otherwise be an implied certification into an express condition for payment. will support an FCA claim. The Medicare claim form adds weight to this position (see Legal Brief). A separate provision of federal law makes filing false claims a criminal offense.27 If convicted, an organization will be subject to huge monetary penalties, perhaps in the millions of dollars depending on the amounts falsely claimed. An individual who is convi