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.
Health care fraud and abuse enforcement activity is at an all-time high yet many physicians and other providers lack a basic understanding of the key healthcare fraud and abuse statutes that apply to them. Although each state may have its own fraud and abuse laws, any healthcare provider that receives federal funds should be familiar… Continue Reading
When it comes to record-breaking Medicare fraud busts, the hits keep coming. The feds announced today another nationwide takedown of physicians and other healthcare providers for Medicare fraud totaling in excess of $450 million. All told, 107 people have been charged in this week’s bust for, among other things, submitting false claims to the Medicare program. … Continue Reading
If you read this blog with any regularity (or even if you read healthcare related news from time to time), you should be aware of the emphasis that federal and state enforcement authorities are placing on healthcare fraud and abuse enforcement. Despite these intensive fraud and abuse enforcement activities, however, many physicians and healthcare providers… Continue Reading
Physicians who reassign their right to bill the Medicare program can still be liable for false claims
I have been speaking with physicians for years about the importance of developing effective fraud and abuse compliance programs in their practices and I often still get the same response: The government is only interested in the big fish like pharmaceutical manufacturers and hospitals -physicians are under the radar. Well, contrary to popular belief, it appears that there… Continue Reading
In June of 2011, I reported on this blog about a software program being launched by the federal Department of Health and Human Services to use a technology called predictive modeling to identify fraudulent and abusive billing practices on a prepayment basis. The program, known as the Fraud Prevention System, was funded through the The… Continue Reading
A recent USDOJ settlement highlights the need for physicians to pay close attention to their dealings with medical device companies.
Federal prosecutors continue to focus their efforts on preventing health care fraud, as evidenced by a recent case arising in Texas. Earlier this year, a Houston doctor (Dr. Christina Clardy) was convicted of three counts of mail fraud, 14 counts of health care fraud and one count of conspiracy to commit health care fraud – all relating to over $45 million in false billings to Medicare and Texas’ Medicaid programs.