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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.

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 ...

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...

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...

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...

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...

  Physician-industry collaboration can produce important medical advances. However, some pharmaceutical and device companies have used sham consulting agreements and other arrangements to buy physician loyalty to their products. Such illegal arrangements induce physicians to prescribe or use pro...

If an investigator from an administrative agency or criminal agency contacts you or comes to your place of business or requests records in writing, the first step you need to take is contacting an attorney experienced in this area of the law. Tracy Green has given lectures to many professional as...

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 ...

If you or your company are the target of a grand jury investigation or have been asked to be a witness in one, questions immediately arise: Should you provide testimony? Should you produce documents? Or, should you exercise your Fifth Amendment rights? Representation for Witnesses, Subjects and ...

Free Samples   Some physicians welcome visits from pharmaceutical salespeople, while other physicians prefer not to directly engage with industry representatives. If you decide to make your practice accessible to salespeople, you probably will be offered product samples. Many drug and biologi...

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. ...

Conflict-of-Interest Disclosures Many of the relationships discussed in this brochure are subject to conflict-of-interest disclosure policies. Even if the relationships are legal, you may have an obligation to disclose their existence. Rules about disclosing and managing conflicts of inter...

Accurate Coding and Billing Payers trust you, as a physician, to provide necessary, cost-effective, and quality care. You exert significant influence over what services your patients receive, you control the documentation describing what services they actually received, and your documentat...

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...

  Some have observed that physicians who invest in health care business ventures with outside parties (e.g., imaging centers, labs, equipment vendors, or physical therapy clinics) refer more patients for the services provided by those parties than physicians who do not invest.   Maybe this d...

If you are engaged in a relationship you think is problematic or have been following billing practices you now realize were wrong:   Immediately cease filing the problematic bills.   Seek knowledgeable legal counsel.   Determine what money you collected in error from your patients and from...

Attorney Tracy Green was quoted in an article by the Los Angeles Times published on May 30, 2018 entitled "LAPD begins sweeping criminal probe of former USC gynegologist while urging patients to come forward."  This is the type of case that is growing due to the media attention which means the ne...

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,...

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...

  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...

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)...

I have received a request for a patient or client file from my licensing board. What should I do? This is the time to be the most proactive. The earlier you can prevent an investigation from going forward by responding to it intelligently and fully, the better. Once an Accusation or disciplina...