Which act would be considered a False Claims Act (FCA) violation under the 'reverse false claims provision' of the FCA?

Which act would be considered a False Claims Act (FCA) violation under the 'reverse false claims provision' of the FCA?

• A. Reporting higher level of E/M code than is supposed by the documentation
• B. Reporting two services together that were identified as bundled by NCCI
• C. Failure to refund an overpayment
• D. Reporting more units than allowed by MUE

Answer: (C)

The key idea here is the reverse false claims provision: knowingly avoiding or concealing an obligation to repay government funds. If you’ve been overpaid and you don’t refund that money, you’re effectively concealing the obligation to return it, which fits the reverse false claims violation. Failing to refund an overpayment demonstrates that concealment and persistence in avoiding repayment. The other scenarios describe misbilling to obtain payment (coding higher levels, unbundling, or claiming more units than allowed), which are classic false claims actions but not the concealment of an obligation to repay an overpayment. In short, not refunding an identified overpayment aligns with the reverse false claims concept.

The key idea here is the reverse false claims provision: knowingly avoiding or concealing an obligation to repay government funds. If you’ve been overpaid and you don’t refund that money, you’re effectively concealing the obligation to return it, which fits the reverse false claims violation.

Failing to refund an overpayment demonstrates that concealment and persistence in avoiding repayment. The other scenarios describe misbilling to obtain payment (coding higher levels, unbundling, or claiming more units than allowed), which are classic false claims actions but not the concealment of an obligation to repay an overpayment. In short, not refunding an identified overpayment aligns with the reverse false claims concept.