Nicely put, Donna.
D. The Difference Between ‘‘Erroneous’’ and ‘‘Fraudulent’’ Claims To Federal Health Programs
There appear to be significant misunderstandings within the physician community regarding the critical differences between what the Government views as innocent ‘‘erroneous’’ claims on the one hand and ‘‘fraudulent’’ (intentionally or recklessly false) health care claims on the other. Some physicians feel that Federal law enforcement agencies have maligned medical professionals, in part, by a perceived focus on innocent billing errors. These physicians are under the impression that innocent billing errors can subject them to civil penalties, or even jail. These impressions are mistaken.
To address these concerns, the OIG would like to emphasize the following points. First, the OIG does not disparage physicians, other medical professionals or medical enterprises. In our view, the great majority of physicians are working ethically to render high quality medical care and to submit proper claims.
Second, under the law, physicians are not subject to criminal, civil or administrative penalties for innocent errors, or even negligence. The Government’s primary enforcement tool, the civil False Claims Act, covers only offenses that are committed with actual knowledge of the falsity of the claim, reckless disregard, or deliberate ignorance of the falsity of the claim.
The OIG is very mindful of the difference between innocent errors (‘‘erroneous claims’’) on one hand, and reckless or intentional conduct (‘‘fraudulent claims’’) on the other. For criminal penalties, the standard is even higher—criminal intent to defraud must be proved beyond a reasonable doubt.