Category: Compliance Programs

Using Artificial Intelligence to Detect Potential Health Care Fraud

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How AI Can Mitigate or Create Fraud and Abuse Risks in the Healthcare Industry The age of Artificial Intelligence is clearly upon us.  Unless you are living in a cave it would be impossible not to understand that it will have an enormous impact on nearly every aspect of society, including the hea...

Compliance Officer Authority and Resource Allocation

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The Department of Justice (DOJ) uses resource allocation as a key measure when evaluating the effectiveness of compliance programs. Allocating sufficient resources to the compliance function is foundational to any systematic compliance initiative and remains central as regulatory expectations evo...

Coronavirus Checklist for Nursing Homes and Hospitals

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Comprehensive Guide to Hospital Readiness and Infection Control Introduction The ongoing threat of coronavirus (COVID-19) requires hospitals to maintain rigorous preparedness and response plans. This detailed checklist is designed to help hospital administrators and healthcare teams ensure readin...

The Incentive to Self Disclose False Claims Act Overpayments

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Proactive Compliance and Regulatory Oversight The Department of Justice (DOJ), in collaboration with other regulatory agencies, places a strong emphasis on the proactive monitoring of compliance by businesses. Recognizing that governmental resources alone are insufficient to uncover every instanc...

Deconstructing the “HIPAA Bias.”

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Understanding HIPAA and Its Interaction with State and Federal Confidentiality Laws HIPAA, the body of regulations designed to protect the confidentiality of patient health care information, has been highly effective in creating widespread awareness within health care facilities. Most staff membe...

DOJs New Evaluation of Corporate Compliance Programs – The Essence of Compliance

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The Criminal Division of the United States Department of Justice (DOJ) revised its Evaluation of Corporate Compliance Programs in April 2019. Initially introduced in 2017, this document provides prosecutors with structured guidance for investigations, charging decisions, and plea negotiations. Th...

Disclosures for Specific Payment or Health Care Operations Purposes (§ 2.33)

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Part 2 Records –  Specific Payment or Health Care Operations Purposes (§ 2.33) Special restrictions apply to health information that is restricted under SAMHSA rules.  These rules protect patient information involving substance and alcohol treatment in Federal programs.  SAMHSA requirements...

Authentication of Verbal Orders by Other Responsible Practitioner

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Prompt Authentication of Verbal Orders ; Verbal Order Risks The failure of a physician to timely sign a verbal order can have reimbursement implications. In some cases, in some states, another responsible provider can sign a verbal order that is originally given by another practitioner. This opti...

Verbal Orders Documentation and Authentication

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The Physician Verbal Order Minefield Physicians often provide orders over the telephone in cases where action must be taken immediately. For example, verbal orders must be given by a physician who is on call or off duty but an issue arises that requires staff to take immediate action. Physician o...

Telemedicine Compliance Series – Licensing Issues in Telehealth

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How Telemedicine Licensing Issues Arise – Compliance for Telehealth Programs The practice of medicine is licensed and regulated at the state level.  The jurisdiction of individual states over medical licensure is broadly recognized by the courts and the federal government, including CMS.  The f...

Failing to Perform an Electronic Access Risk Analysis Before and Unauthorized Access Occurs

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OCR Settlement Lessons – No Risk Assessment Exposes Provider to Liability Failure to conduct a risk assessment before a hacking incident occurred resulted in a $400,000 settlement between OCR and a Federally Qualified Health Clinic.  The FQHC filed a breach report upon learning that its employee...

Designated Health Services Definition I Stark Law DHS Defined

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Definition of Designated Health Services under the Stark Law Regulations Designated health services (DHS) means any of the following services (other than those provided as emergency physician services furnished outside of the U.S.), as they are defined in this section: (1)(i) Clinical laboratory ...

Can Overpayments Create Criminal Liability?

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We hear a lot about potential liability under the False Claims Act (FCA) for the failure to repay overpayments within 60 days of discovery. Focus on the 60-day rule has taken focus away from the potential for criminal charges for retaining known overpayments.  Section 1128B(a)(3) of the Social S...

Defining the Duty of the Board of Directors over Compliance Functions

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Compliance Program Oversight by Board of Directors I recently posted a blog article about a document released by the Department of Justice entitled “Evaluation of Compliance Programs.”  As the title of the document might suggest, the DOJ release covers a variety of issues it looks at when ev...

Self Disclosure Process – Voluntary Self Disclosure Decisions are not Always Easy

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Provider Self Disclosure Decisions – Voluntary Disclosure Process The HHS Office of Inspector General offers providers and opportunity to self-disclose certain violations in exchange for avoiding some of the more draconian penalties that may otherwise apply under applicable regulations.  Even ...

What Does the HIPPA Phase2 Audit Program Mean for Physicians?

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HIPAA Audits of Physician Practices – Phase II Audits The HHS Office for Civil Rights (“OCR”) has Officially announced The commencement of its 2016 Phase 2 HIPAA Audit . In Phase 2, OCR Will be reviewing the policies and procedures of covered entities and their business associates. This phase of ...