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Most doctors bill their Medicare claims correctly. However, there are a few physicians – and their employers – who engage in upcoding and similar activities and risk the harsh penalties of the False Claims Act (FCA).

As many of our Michigan blog’s readers know, the Department of Justice (DOJ) last year increased the penalties that can be assessed under the FCA – a federal statute that dates back to 1863. In fact, the FCA was enacted during the Civil War to stem defense contractor fraud.

Today, the statute enables the federal government to pursue perpetrators of fraud, and it also allows private citizens to file lawsuits (called “qui tam” suits) on behalf of the gov

The independent pharmacy community’s wait began back in Michigan's frigid  January when the U.S. Supreme Court decided it would take Rutledge v. the Pharmaceutical Care Management Association (PCMA). In October, the court heard arguments in the health care law dispute over whether states can regulate pharmacy benefit managers (PBMs).

With its recent unanimous decision, the court ended the wait by ruling that states may pass laws requiring PBMs to reimburse pharmacies for medications at a rate equal to – or higher than – the pharmacy’s wholesale cost.

The leg

Your primary duty is to care for your patient. Unfortunately, you aren’t given carte blanche to do so. Your care must fall within the lines of hospital and clinic rules. There are also state and federal regulations to which you must adhere, as well as your ethical obligations.

All of these factors can impede your ability to provide the type of care you feel your patient deserves. Sometimes, it can be tempting to flout the rules to help your patient get the treatment they need. Some medical professionals may perform an end-run around rules and regulations by engaging in a practice known as upcoding. While you may believe you are doing what is morally right, upcoding is considered a