Category: Fraud and Abuse

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...

Senate Subcommittee (November 2023): Policy Considerations for AI in Health Care

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In November 2023, the Subcommittee on Primary Health and Retirement Security under the Senate Committee on Health, Education, Labor and Pensions held a hearing to examine the implications of artificial intelligence (AI) in health care. The hearing brought together lawmakers, technology experts, h...

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...

Apply the 60-Day Repayment Rule to Medicaid Overpayments

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Overview of Overpayment Reporting and Repayment The Affordable Care Act (ACA) imposes specific requirements on individuals and entities that receive overpayments from designated government health programs. Under the ACA, any person who has received an overpayment from programs such as Medicare Pa...

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...

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...

CMS Stark Law Self Disclosure – New Form and Process for Self Disclosing Stark Law Violations

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The Centers for Medicare and Medicaid Services (CMS) has issued new forms and procedures for provider self-disclosure of Stark Law violations. The new material is intended to streamline the process that permits providers to self-disclose Stark Law violations.  The process is applicable to violat...

Remuneration Under the Stark Law I Stark Regulations Definition

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Remuneration Defined Under the Stark Law Regulations Remuneration means any payment or other benefit made directly or indirectly, overtly or covertly, in cash or in kind, except that the following are not considered remuneration for purposes of this section: (1) The forgiveness of amounts owed fo...

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 ...

Ambulatory Surgery Center Exclusions – ASC Safe Harbor Compliance

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Excluding Non-performing Positions from a Physician Owned Surgery Center Many surgery centers are eventually faced with decisions about how to treat investing physicians who do not perform as many procedure procedures in the surgery center as others.  Under-performing physicians can create polit...

Fair Market Value Definition – Stark Law and Safe Harbor Regulations

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Stark Law Definition of Fair Market Value The term “fair market value” means the value in arm’s-length transactions, consistent with the general market value. ‘‘General market value’’ means the price that an asset would bring, as the result of bona fide bargaining between well-infor...

Revision to Medicare oversight or provider based status.

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Hospital Provider Based Status Review OIG 2016 Work Plan Coverage   There’s a lot of activity in the area of provider based facilities and hospitals outpatient departments. Laws are changing to equalize reimbursement that is available between provider-based and physician office settings. Service...

New 2016 Work Plan Indicates Area of Compliance Focus

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OIG 2016 Work Plan Highlights Areas of Fraud and Abuse Concern Each year the Office of Inspector General puts out a work plan that indicates the priorities that it will look up at during the upcoming year. The OIG is an organization that was created to protect the integrity of the HHS program ope...

Ambulatory Surgery Center Forced Exclusions – lets be honest for a minute, shall we?

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Excluding Non-performing Positions from a Physician Owned Surgery Center   Many surgery centers are eventually faced with decisions about how to treat investing physicians who do not perform as many procedure procedures in the surgery center as others.  Under-performing physicians can create pol...

Definition of Remuneration Under the Federal Stark Law

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Remuneration Under the Stark Law Under the Stark Law, “remuneration” is defined broadly to include any payment or other benefit provided directly or indirectly, whether overtly or covertly, and whether in cash or in kind. This comprehensive definition is intentionally expansive to capture a wide ...

Medical Director Agreement Payments May Be Source of Stark Law Compliance Concerns

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MEDICAL DIRECTOR PAYMENTS AS STARK LAW VIOLATIONS The relatively recent case serves as a reminder of the potential exposure to Stark Law liability arising from payments to medical directors.  Let me immediately clarify that not all payments to directors who perform legitimate services that are a...