Such problems often occur, Braver says, when practices rely on billing software to type in codes. But now, as a result of new technology, the government is able to identify violations more quickly and easily than ever before.
As you begin your career, it is crucial to understand these laws not only because following them is the right thing to do, but also because violating them could result in criminal penalties, civil fines, exclusion from the Federal health care programs, or loss of your medical license from your State medical board.
False Claims Act [31 U. It is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent.
Under the civil FCA, each instance of an item or a service billed to Medicare or Medicaid counts as a claim, so fines can add up quickly. The fact that a claim results from a kickback or is made in violation of the Stark law also may render it false or fraudulent, creating liability under the civil FCA as well as the AKS or Stark law.
Under the civil FCA, no specific intent to defraud is required. The civil FCA defines "knowing" to include not only actual knowledge but also instances in which the person acted in deliberate ignorance or reckless disregard of the truth or falsity of the information.
Further, the civil FCA contains a whistleblower provision that allows a private individual to file a lawsuit on behalf of the United States and entitles that whistleblower to a percentage of any recoveries. Whistleblowers could be current or ex-business partners, hospital or office staff, patients, or competitors.
There also is a criminal FCA 18 U. Criminal penalties for submitting false claims include imprisonment and criminal fines. Physicians have gone to prison for submitting false health care claims.
OIG also may impose administrative civil monetary penalties for false or fraudulent claims, as discussed below. Anti-Kickback Statute [42 U. Remuneration includes anything of value and can take many forms besides cash, such as free rent, expensive hotel stays and meals, and excessive compensation for medical directorships or consultancies.
In some industries, it is acceptable to reward those who refer business to you. However, in the Federal health care programs, paying for referrals is a crime.
The statute covers the payers of kickbacks-those who offer or pay remuneration- as well as the recipients of kickbacks-those who solicit or receive remuneration.
Criminal penalties and administrative sanctions for violating the AKS include fines, jail terms, and exclusion from participation in the Federal health care programs.
Safe harbors protect certain payment and business practices that could otherwise implicate the AKS from criminal and civil prosecution.
To be protected by a safe harbor, an arrangement must fit squarely in the safe harbor and satisfy all of its requirements. Some safe harbors address personal services and rental agreements, investments in ambulatory surgical centers, and payments to bona fide employees.
You decide what drugs your patients use, which specialists they see, and what health care services and supplies they receive. Just as it is illegal for you to take money from providers and suppliers in return for the referral of your Medicare and Medicaid patients, it is illegal for you to pay others to refer their Medicare and Medicaid patients to you.
Kickbacks in health care can lead to:A public health emergency has been declared in California amid deadly wildfires. Its easy to write about what the government or other people should do with our/their money. It’s harder to come up with a course of action that I can undertake on my own that possibly, somehow could .
Mr. Michael Pento serves as the President and founder of Pento Portfolio Strategies. He is a well-established specialist in the Austrian School of economics and a regular guest on CNBC, Bloomberg, FOX Business News and other national media outlets.
A subset of this post could be white people who get offended by seemingly banal matters, like waiting too long for a bus and threatening to write a strongly worded letter to the powers-that-be. Health care fraud and abuse costs Americans Whether this is really going to happen; only time will tell.
Healthcare Fraud Healthcare Abuse. I received a message last week from a savvy reader, a former McKinsey partner who has also done among other things significant pro-bono work with housing not-for-profits (as in he has more interest and experience in social justice issues than most people with his background).