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Roadmap to Federal Fraud and Abuse Laws

Posted by Tracy Green | Jan 09, 2020 | 0 Comments

All health care providers, whether individual providers or businesses, need to become educated about federal and state fraud and abuse laws that apply to them. The five most important Federal fraud and abuse laws that apply to physicians are the False Claims Act (FCA), the Anti-Kickback Statute (AKS), the Physician Self-Referral Law (Stark law), the Exclusion Authorities, and the Civil Monetary Penalties Law (CMPL). Government agencies, including the Department of Justice, the Department of Health & Human Services Office of Inspector General (OIG), and the Centers for Medicare & Medicaid Services (CMS), are charged with enforcing these laws.

What Is Upcoding?

Posted by Tracy Green | Dec 11, 2019 | 0 Comments

Upcoding Medicare pays for many physician services using Evaluation and Management (commonly referred to as “E&M”) codes. New patient visits generally require more time than follow-up visits for established patients, and therefore E&M codes for new patients command higher reimbursement rates ...

What is the False Claims Act ?

Posted by Tracy Green | Dec 05, 2019 | 0 Comments

The False Claims Act makes it illegal to submit false or fraudulent claims for payment to Medicare or Medicaid.   Claims  may be false if the service is not actually rendered to the patient, is provided but already covered under another claim, is miscoded, or is not supported by the medical...

Tips for Medical Directors

Posted by Tracy Green | Nov 09, 2019 | 0 Comments

Tips for Medical Directors If you choose to accept a medical directorship at a nursing home, medical clinic, surgery center or other facility, you must be prepared to assume substantial professional responsibility for the care delivered at the facility.   As medical director, patients (both your own patients and the pati...

Telemedicine: Companies That Rely on a Telemedicine Model Face Scrutiny. Recent Indictment Shows Anti-Kickback and Health Care Fraud Issues

Posted by Tracy Green | Sep 10, 2019 | 0 Comments

Telemedicine is often used to recruit physicians and patients and make it easy for physicians to prescribe patients medicine or durable medical equipment. The physicians who agree to work for these companies need to ensure that the companies' practices are compliant with the laws and regulations....

What Does A Doctor, Dentist, Physicians Assistant, Naturopathic Doctor or Nurse Practitioner Need to Do If Prescriptions Pads Are Lost Or Stolen?

Posted by Tracy Green | Apr 23, 2019 | 0 Comments

The reporting requirements for lost or stolen prescription pads are fairly clear but sometimes providers forget to take the needed steps in order to protect themselves. If you're a provider who suspects that your prescription pads have been lost, stolen or forged, you need to take the following s...

Case Study: Are Payments to Referral or "Scheduling" Services Legal? Recent Charges Against Riverside Chiropractor Show Some of the Legal Issues That Can Arise.

Posted by Tracy Green | Aug 11, 2018 | 0 Comments

There are many state and federal laws that govern the payments for marketing or referral services for health care patients. Workers' compensation patients in California are also governed by the Labor Code. It is critical to have these type of arrangements reviewed by experienced counsel to ensure...

Prime Healthcare Services and its CEO Agree to Pay $65 Million to Settle Medicare Overbilling Allegations at 14 California Hospitals

Posted by Tracy Green | Aug 06, 2018 | 0 Comments

On August 3, 2018, Prime Healthcare Services, Inc.; Prime Healthcare Foundation, Inc.; Prime Healthcare Management, Inc.; and Prime's Founder and chief executive officer, Dr. Prem Reddy, agreed to pay the United States $65 million to settle allegations that 14 Prime hospitals in California knowin...

What Is A Federal Indictment?

Posted by Tracy Green | Jul 09, 2018 | 0 Comments

What is a federal indictment? An indictment is a formal accusation against one or more defendants, charging them with one or more crimes. In the federal criminal system, the indictment is the principal method by which a prosecutor initiates criminal proceedings. For certain types of crimes, and ...

Why Should I Establish A Compliance Program?

Posted by Tracy Green | Jun 20, 2018 | 0 Comments

Establishing and following a compliance program will help physicians avoid fraudulent activities and ensure that they are submitting true and accurate claims. The following seven components provide a solid basis upon which a physician practice can create a voluntary compliance program:   1. ...

Physician Recruitment Basics

Posted by Tracy Green | Jun 04, 2018 | 0 Comments

Physician Recruitment   A hospital will sometimes provide a physician with a recruitment incentive to induce the physician to relocate to the hospital's geographic area, become a member of its medical staff, and establish a practice that helps serve that community's medical needs. Often, su...

What is the Federal Civil Monetary Penalties Law ?

Posted by Tracy Green | May 27, 2018 | 0 Comments

Civil Monetary Penalties Law [42 U.S.C. § 1320a-7a] OIG may seek civil monetary penalties and sometimes exclusion for a wide variety of conduct and is authorized to seek different amounts of penalties and assessments based on the type of violation at issue. Penalties range from $10,000 to $50,...

What is OIG Exclusion?

Posted by Tracy Green | May 27, 2018 | 0 Comments

Exclusion Statute [42 U.S.C. § 1320a-7] OIG is legally required to exclude from participation in all Federal health care programs individuals and entities convicted of the following types of criminal offenses: (1) Medicare or Medicaid fraud, as well as any other offenses related to the deliver...

What is the Physician Self-Referral Law or Stark Law?

Posted by Tracy Green | May 26, 2018 | 0 Comments

  The Physician Self-Referral Law, [42 U.S.C. § 1395nn] commonly referred to as the Stark law, prohibits physicians from referring patients to receive “designated health services” payable by Medicare or Medicaid from entities with which the physician or an immediate family member has a financ...

What Is The Federal Anti-Kickback Statute?

Posted by Tracy Green | May 21, 2018 | 0 Comments

The five most important Federal fraud and abuse laws that apply to physicians and some other health care providers are the False Claims Act (FCA), the Anti-Kickback Statute (AKS), the Physician Self-Referral Law (Stark law), the Exclusion Authorities, and the Civil Monetary Penalties Law (CMPL)...

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