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Can a physician be fined or prosecuted because they mistakenly send improper bills to Medicare? Many physicians think so, but the federal Office of Inspector General (OIG) says no.
Writing in the October 5, 2000 Federal Register, OIG noted that Medicare and Medicaid fraud must be the result of intentional or recklessly false claims filing. They wrote "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 False Claims Act does not encompass mistakes, errors, or negligence."
OIG noted that another legal tool, the Civil Monetary Penalties Law, has exactly the same standard of proof for administrative action. "For criminal penalties, the standard is even higher-criminal intent to defraud must be proved beyond a reasonable doubt." OIG said that a provider billing mistake that is the result of an inadvertent act or negligence-an honest mistake-should only result in the return of Medicare or Medicaid payment and that no penalties can be enforced.