What It Is
A federal law that penalizes fraud against government healthcare programs (Medicare, Medicaid, TRICARE).
How It Applies to Medical Billing
✔ Upcoding (billing for a more expensive service than performed)
✔ Unbundling (billing separately for services that should be bundled)
✔ Billing for services not rendered
✔ Falsifying medical necessity
Consequences of Violations
- Financial penalties: 11,000−11,000−23,000 per claim + 3x damages
- Exclusion from federal healthcare programs
- Criminal charges for intentional fraud
How to Stay Compliant
- Audit claims regularly for coding accuracy
- Train staff on proper documentation and billing
- Implement compliance programs with clear reporting channels
