Which scenario could trigger FCA/AKS exposure?

Which scenario could trigger FCA/AKS exposure?

• A. Submitting a claim to Medicare that the filer knows is false.
• B. Providing a legitimate service with proper documentation.
• C. Paying a referral source a kickback disclosed to CMS under an allowed safe harbor.
• D. Submitting a claim with accurate coding.

Answer: (A)

Submitting a Medicare claim that you know is false directly tests liability under the False Claims Act. The FCA targets presenting or causing to be presented to the government a claim for payment that is false or fraudulent. Importantly, “knowingly” includes actual knowledge of falsity, deliberate blindness to it, or reckless disregard for the truth. So when a filer knowingly submits a claim that is false, that falls squarely under FCA exposure. The Anti-Kickback Statute comes into play with improper remunerations to induce referrals. If a payment to a referral source is truly within an allowed safe harbor, it may be permitted under AKS. However, AKS compliance by itself doesn’t negate FCA risk if a claim is knowingly false—the government can still pursue FCA liability for the false claim. Providing a legitimate service with proper documentation or submitting a claim with accurate coding would not trigger FCA/AKS exposure.

Submitting a Medicare claim that you know is false directly tests liability under the False Claims Act. The FCA targets presenting or causing to be presented to the government a claim for payment that is false or fraudulent. Importantly, “knowingly” includes actual knowledge of falsity, deliberate blindness to it, or reckless disregard for the truth. So when a filer knowingly submits a claim that is false, that falls squarely under FCA exposure.

The Anti-Kickback Statute comes into play with improper remunerations to induce referrals. If a payment to a referral source is truly within an allowed safe harbor, it may be permitted under AKS. However, AKS compliance by itself doesn’t negate FCA risk if a claim is knowingly false—the government can still pursue FCA liability for the false claim.

Providing a legitimate service with proper documentation or submitting a claim with accurate coding would not trigger FCA/AKS exposure.