Many physicians mistakenly believe that federal healthcare fraud and abuse statutes only apply to the Medicare fee-for-service program. However, physicians need to be aware that many federal healthcare statutes apply to any program or plan funded, in whole or in part, with federal dollars. One such example is the Medicare Advantage program. Although these plans… Continue Reading
By J. Benjamin Nevius The United States Court of Appeals for the Seventh Circuit recently issued an interesting decision concerning the definition of “referral” in the context of federal anti-kickback laws. See U.S. v. Patel, No. 14–2607, 2015 WL 527549 (7th Cir. 2015). In the Patel matter, the United States charged a Chicago-area physician with… Continue Reading
A physician who was excluded from the Medicare program is not precluded from receiving payment for services rendered prior to the exclusion according to Advisory Opinion 15-02 published by the HHS Office of Inspector General (OIG) earlier this month. The Advisory Opinion was requested by a physician who was excluded for 20 years from Medicare… Continue Reading
Each year, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) publishes a Work Plan for the coming fiscal year which summarizes new and ongoing reviews and activities that the OIG plans to pursue with respect to HHS programs and operations during the current fiscal year and beyond. For physicians… Continue Reading
Physician ancillary service joint ventures continue to proliferate and not surprisingly, federal and state regulators are on the lookout for arrangements which may violate fraud and abuse laws . In its recent “Special Fraud Alert: Laboratory Payments to Referring Physicians”, the Office of Inspector General (OIG) has (once again) expressed concern over financial arrangement between… Continue Reading
One of the often overlooked requirements in the federal Affordable Care Act is that healthcare providers now have an obligation to refund overpayments to the Medicare within 60 days of discovery. Failing to do so may expose a provider to liability under the federal False Claims Act and possible exclusion from the Medicare program. Late last week, the Department of Justice elected to… Continue Reading
The Office of Inspector General (OIG) today issued a proposed rule which would amend the federal civil monetary penalty (CMP) regulations addressing new CMP authorities created under the Affordable Care Act. The revised regulations would allow for civil penalties, assessments, and exclusion from Medicare for and of the following: Failure to grant OIG timely access… Continue Reading
Many physicians I speak with are still surprised to learn that the federal Stark statute imposes restrictions on income division within group practices. These restrictions only apply to profits generated from any of the Stark “designated health services” and only those that are covered by Medicare and Medicaid (including managed care), but if your group provides… Continue Reading
It is still evident to me that too many physician practices still do not have effective fraud and abuse compliance programs integrated into their practices. To date there has been no federal or state mandate that physicians implement a compliance program but such a mandate is coming. In fact, the Affordable Care Act of 2010… Continue Reading
One of the ways the Medicare program and other payer plans are recovering overpayments and identifying billing fraud is through the regular use of data mining. Simply put, by utilizing software programs that monitor and compare billing and coding data, enforcement authorities are easily able to identify problematic trends in physician billing. This is an extremely… Continue Reading
Earlier this month the closely watched case of U.S. ex rel Drakeford v Tuomey Healthcare System Inc. (675 F.3d 394 (4th Cir. 2012) concluded with a jury finding that the compensation paid to physicians under certain part-time employment agreements by Tuomey Healthcare System resulted in violations of both the federal False Claims Act and the… Continue Reading
On March 26, 2013, the Office of Inspector General published much-awaited guidance on physician-owned medical device distributorships (commonly known as “PODs”) in the form of a Special Fraud Alert. The OIG makes no bones about where it stands on PODs which it describes as “physician-owned entities that derive revenue from selling, or arranging for the… Continue Reading
In what would undoubtedly be a devastating blow to many medical practices that rely on the Stark in-office ancillary services exception (which allows physicians to refer within their practices for Stark services), President Obama’s proposed FY 2014 would seek to eliminate the exception for physical therapy, radiation therapy and advanced imaging such as CT and… Continue Reading
Yesterday the U.S. Department of Justice announced that it has entered into a $26M False Claims settlement with a dermatologist in Florida. According to the DOJ, this is one of the largest False Claims settlements against an individual in history. The physician was accused of allegedly accepting kickbacks from a pathology lab and billing for medically… Continue Reading
The Obama administration announced today that as a result of increased federal health care fraud and abuse enforcement efforts, the federal government recovered $4.2 billion in 2012, setting a new record. According to the Department of Health and Human Services, for every $1 spent on enforcement efforts, they recouped $7.90. For more on the topic… Continue Reading
State’s “more stringent” Stark law restrictions upheld by court.
This week the Office of Inspector General published an interesting Advisory Opinion (AO 12-22) dealing with a cardiology co-management agreement between a hospital and a private cardiology group practice.
OIG has announced its priorities for 2013 and some are of special interest to physicians.
Physicians in private practice are increasingly relying upon their local hospitals for assistance in making the transition to full-fledged electronic medical records. The Office of Inspector General (OIG) of the Department of Health and Human Services recently gave the nod to a proposed arrangement which would enhance electronic communication between private practices and a community… Continue Reading
This week the Office of Inspector General of the Department of Health and Human Services published Advisory Opinion 12-15 in which it blessed an on-call compensation arrangement between a hospital and specialist physicians on its staff.
Many physicians were once content (and a few still are) to let their coders select their codes for billing purposes. At a time when enforcement authorities have some heavy-duty technological weapons for identifying improper billing, physicians can no longer avoid learning the billing rules applicable to their services. Consider this recent settlement related to the… Continue Reading
In my experience, many healthcare providers fail to take seriously the importance of fair market value in their business arrangements. In fact, one of the most important means of ensuring compliance with federal and state fraud and abuse laws such as the federal anti-kickback and Stark is to ensure that financial arrangements – particularly where there are referrals relationships -are consistent with fair market value. … Continue Reading
Recent press releases provide notice of activities that draw the government’s ire — and result in serious criminal consequences. Focusing on these issues is a helpful exercise for any physician trying to stay within the law.
A recent court decision concerns the method of rotating teaching physicians between multiple surgeries and billing Medicare for those services, and “whistleblower” claims when improperly done.