Which action would be considered a reverse false claims provision violation under FCA?

Which action would be considered a reverse false claims provision violation under FCA?

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

Answer: (A)

The action being tested is the reverse false claims concept: knowingly retaining an overpayment from government funds. Under the False Claims Act, if you identify an overpayment, you must refund or return it within 60 days; failing to do so means you are keeping money you’re not entitled to, which constitutes a reverse false claims violation. In this scenario, not refunding the overpayment directly fits that violation. The other options describe submitting or supporting improper claims through coding or billing practices (like billing more units, upcoding, or unbundling when bundled), which are traditional false claims issues rather than reverse ones.

The action being tested is the reverse false claims concept: knowingly retaining an overpayment from government funds. Under the False Claims Act, if you identify an overpayment, you must refund or return it within 60 days; failing to do so means you are keeping money you’re not entitled to, which constitutes a reverse false claims violation.

In this scenario, not refunding the overpayment directly fits that violation. The other options describe submitting or supporting improper claims through coding or billing practices (like billing more units, upcoding, or unbundling when bundled), which are traditional false claims issues rather than reverse ones.