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© 2009 Cengage Learning. All Rights Reserved. Healthcare Fraud and Abuse
© 2009 Cengage Learning. All Rights Reserved. Agenda False Claims Act (FCA) Anti-Kickback Statute (AKS) Self-Referral Law (“Stark”) Health Insurance Portability and Accountability Act (HIPAA) Criminal and Civil Penalties Roles of Agencies Corporate Compliance Programs
© 2009 Cengage Learning. All Rights Reserved. Basic Rule in Healthcare Billing “No payment shall be made for services or items which are not reasonable and necessary for the diagnosis and treatment of the patient.” Don’t bill for wrong side surgeries, for dead patients, for services of unlicensed doctors, for lab equipment you don’t have, for surgeries if surgeon is out of the country, etc.
© 2009 Cengage Learning. All Rights Reserved. False Claims Act (FCA) 32 U.S.C et seq A false claim is a request for payment for a service or item that is not reasonable or necessary for the diagnosis or treatment of the patient. FCA applies to any person or entity (e.g. doctor, hospital, etc.) who knowingly presents a fraudulent or false claim to the government for approval or payment
© 2009 Cengage Learning. All Rights Reserved. False Claims Act contd. Misconduct related to the submission of claims to federal healthcare programs can be grounds for civil suit, criminal prosecution, or administrative remedies. Civil suits under the FCA may be brought by the federal government or by private individuals, known as qui tam relators.
© 2009 Cengage Learning. All Rights Reserved. Anti-Kickback Statute (AKS) 42 U.S.C. 1320a-7(b) AKS makes it a felony to knowingly and willfully solicit or receive remuneration “in return for referring an individual to a person for the furnishing or arranging for the furnishing of an item or service” or “for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any good, facility, service, or for which payment may be made in whole or in part under a Federal healthcare program.”
© 2009 Cengage Learning. All Rights Reserved. Anti-Kickback Statute contd. Congress established statutory exceptions, known as “safe harbors,” for certain payment practices that it considers not to be prohibited referrals. Criteria: (1) if the purpose of the payment is to induce referrals and (2) if the defendant’s conduct is knowing and willful. (see U.S. v. Greber) AKS applies to any person or entity (e.g. ambulance, DME. etc.)
© 2009 Cengage Learning. All Rights Reserved. Self-Referral Law (“Stark”) Stark prohibits certain physician referrals to other entities. Stark deals directly with over-utilization of services by targeting referrals by “financially-interested” physicians. Stark applies to certain designated health services (DHS). Congress created exceptions to legitimize some financial relationships. Stark applies only to physicians.
© 2009 Cengage Learning. All Rights Reserved. Health Insurance Portability and Accountability Act (HIPAA) 18 U.S.C HIPAA is not just about patient confidentiality! HIPAA expanded healthcare fraud and abuse criminal prosecutions and enhanced criminal penalties.
© 2009 Cengage Learning. All Rights Reserved. Criminal and Civil Penalties Criminal laws include: section 1128B of the Social Security Act false claims, or applications to the government or payment (18 U.S.C. 287) false statements or representations or disclosures made to the government (18 U.S.C. 1001), and mail fraud and wire fraud (18 U.S.C et seq).
© 2009 Cengage Learning. All Rights Reserved. Criminal and Civil Penalties Civil penalties include: exclusions from federal healthcare programs civil monetary penalties, and other administrative sanctions.
© 2009 Cengage Learning. All Rights Reserved. False Claim Penalties Punishable by treble damages (3 times amount of claim or loss to federal government) PLUS fines of up to $11,000 per claim
© 2009 Cengage Learning. All Rights Reserved. Roles of Agencies DHHS has oversight over federally funded healthcare programs. DHHS/OIG investigates fraud and abuse, issues fraud alerts, provides compliance guidance, participates in settlements, and oversees Corporate Integrity Agreements. DOJ prosecutes criminal healthcare fraud and abuse and institutes civil proceedings.
© 2009 Cengage Learning. All Rights Reserved. Corporate Compliance Programs Every healthcare organization should have a corporate compliance program. Federal Sentencing Guidelines are legal source of authority. Main elements are: compliance standards high level responsibility education communication monitoring and auditing enforcement and discipline response and prevention.
© 2009 Cengage Learning. All Rights Reserved. Corporate Compliance Programs contd. Corporate Integrity Agreements mandate certain requirements for offending organizations. CIAs are usually 5 years. CIAs are used in negotiation settlements in fraud and abuse cases.
Learning Module #2 HIPAA and Compliance For Clinical Students and Instructors FVHCA Member Clinical Sites Reviewed
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Protecting Patient Privacy: HIPAA Guidelines for Health Care Providers.
Fair Market Value and Payments to Healthcare Professionals – How Should We Determine What We Pay? © Huron Consulting Services LLC. All rights reserved.
1 FINANCIAL DISCLOSURES AND CONFLICTS OF INTEREST IN CLINICAL RESEARCH Richard S Liner, JD Ronald H. Clark, PhD, JD Arent Fox Kintner Plotkin & Kahn, PLLC.
© 2008 Smith Moore Leatherwood LLP. ALL RIGHTS RESERVED. Presented by: Terrill Johnson Harris Allyson Jones Labban Smith Moore Leatherwood LLP 300 North.
1 HIPAA Privacy Basics Presented by: Michele A. Masucci Harvey Z. Werblowsky McDermott, Will & Emery October 30, 2002.
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Mississippi DOM Fraud, Waste, and Abuse (FWA) and HIPAA Training UPDATED 4/1/2014.
© Copyright 2010 National Association of Community Health Centers. All rights reserved.
Group Practice Requirements & Advantages Under the Stark Law Rob Stone, Esq. Alston + Bird Presentation for Georgia Hospital Association January 30, 2009.
Assessing FMV in Hospital/Physician Arrangements: What Healthcare Executives Should Know September 3, 2009.
1 HIPAA Privacy Standards Health Insurance Portability and Accountability Act – HIPAA Privacy Standards Healthcare Provider Training Module Copyright 2003.
Vendor Management September 7 th 2007 James Mahan, Vice President Yankee Alliance.
SIMPLIFYING PRIVACY: HIPAA PRIVACY STANDARDS AND RESEARCH Angela M. Vieira General Counsel Childrens Hospital and Health Center June 5, 2004.
Perspectives From Experienced Government Counsel, Relator’s Counsel & Defense Counsel 17 th Annual FLABOTA Convention Friday, July 18 th, 2014 The Breakers.
HIPAA Training: Ensuring Privacy for our Patients Privacy Training for Harvard Medical Students.
CHAA Examination Preparation Pre-Encounter - Session IV Pages University of Mississippi Medical Center.
Billing 3 rd Party Payors for Services as part of Clinical Research Presented by OCRA to the Research Committee March 3, 2010.
Viveca D. Parker Assistant United States Attorney 615 Chestnut Street, Suite 1250 Philadelphia, PA Phone: (215)
Copyright Davis Wright Tremaine LLP - Jan Working with the HIPAA Privacy Manual and Forms --- HIPAA Summit West II Clark Stanton & Tom Jeffry Davis.
HIPAA: An Overview of Transaction, Privacy and Security Regulations Training for Providers and Staff.
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Fiscal Guidelines/ Budget and Program Revisions NC Committee on Dropout Prevention Procedures Manual 2010.
MEDICAL ETHICS, LAW, AND COMPLIANCE Chapter 2. 2 Medical Ethics, Law, and Compliance Learning Objectives Define medical ethics, bioethics, and etiquette.
Copyright 2008 The Regents of the University of California All Rights Reserved The Regents of the University of California accepts no liability for any.
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