Under the False Claims Act, those who knowingly submit or cause another person or entity to submit false claims for payment of government funds are liable for three times the government’s damages plus civil penalties of a minimum of $11,665 and a maximum of $23,331 (as of June 2020) per false claim.

To learn more about qui tam whistleblower provisions, employee protection, self-auditing and Affordable Care Act expansion of the False Claims Act, please see the "provider billing and reimbursement" chapter of the provider manual.

Fraud refers to any type of intentional deception or misrepresentation, including any act that constitutes fraud under applicable federal or state law, made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity or person, or some other person in a managed care setting, committed by any entity, including the PH-MCO, a subcontractor, a provider, or a member, among others.

Waste refers to the overutilization of services or other practices that result in unnecessary costs. Waste is generally not considered caused by criminally negligent actions, but rather misuse of resources.

Abuse refers to any practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary costs or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards or agreement obligations, including the requirements of state or federal regulations for health care in a managed care setting. Abuse also includes member practices that result in unnecessary cost to the MA Program, the PH-MCO, a subcontractor, or provider.