False Claims Act
The False Claims Act (FCA) is the federal government's primary tool for combating fraud against programs like Medicare and Medicaid. It imposes civil liability on anyone who knowingly submits, or causes the submission of, false or fraudulent claims for payment, with remedies that include treble damages and substantial per-claim penalties. Home health has been a sustained FCA enforcement focus for decades. This page is educational and general, not legal advice.
What "knowingly" means
The FCA does not require intent to defraud. "Knowingly" covers actual knowledge, deliberate ignorance of the truth, and reckless disregard for it. Honest mistakes and mere negligence are not FCA violations, but a billing operation that ignores repeated warning signs, skips claim review, or keeps billing through known documentation problems can cross into recklessness. That framing matters for operators: the defense is not perfection, it is a functioning system that catches and corrects errors, and a record showing the agency responded when problems surfaced.
Qui tam: the whistleblower engine
Most FCA cases start with a qui tam relator, a private person, very often a current or former employee, who files a sealed complaint on the government's behalf. The government investigates and decides whether to intervene, and successful relators receive between 15 and 30 percent of the recovery, plus protection from retaliation. For home health agencies the operational lesson is cultural: clinicians and billers who raise concerns internally and see them addressed rarely become relators. Retaliating against someone who raises billing concerns is both an independent violation and a reliable way to turn a fixable problem into litigation.
Home health risk areas
Enforcement actions in home health cluster around familiar theories:
- Billing for patients who were not homebound or had no skilled need
- Visit notes that do not support the services billed, or were falsified outright
- Inaccurate OASIS answers that inflate payment
- Certifications signed without valid face-to-face encounters, or forged practitioner signatures
- Claims tainted by kickbacks to referral sources
- Keeping identified overpayments instead of returning them
The 60-day overpayment rule
The FCA has a reverse false claims provision: knowingly concealing or improperly avoiding an obligation to pay the government is itself a violation. Under the Affordable Care Act, a Medicare overpayment must be reported and returned within 60 days of being identified, meaning the provider has, or should have through reasonable diligence, determined and quantified it. An agency that finds a pattern of unsupported claims and quietly keeps the money converts a billing problem into FCA exposure. The playbook is to investigate promptly, quantify honestly, and repay or self-disclose on time.
Frequently asked questions
What are the penalties under the False Claims Act?
Up to three times the government's damages plus a civil penalty for each false claim, with per-claim amounts adjusted annually for inflation and currently in the five figures. Because home health billing generates high claim counts, per-claim penalties can dwarf the underlying payments.
Is keeping an overpayment really a false claim?
It can be. Knowingly retaining a Medicare overpayment beyond 60 days after identifying it violates the FCA's reverse false claims provision, even though the original claim may have been an innocent error. Timely investigation and repayment are the safeguards.
What should we do if we suspect a billing problem?
Preserve records, investigate quickly, and quantify the scope, then repay or use the appropriate self-disclosure pathway if claims were improper. Bring in experienced healthcare counsel early; how an agency responds after discovering a problem heavily influences whether it becomes an FCA matter.