The Fight Against Medicare Fraud and Abuse

Fighting Medicare Fraud and Abuse 

The health care reform legislation contains several provisions that affect fraud investigations and over-payments. One change that you will want to really keep an eye on is the change that permits HHS to suspend payments to you while an investigation is taking place if the investigation results from a “credible allegation of fraud.” The bill does not contain any definitions of what constitutes a “credible allegation of fraud” or how this new authority will be implemented. The HHS Secretary will have the authority to promulgate regulations covering all of these types of details.

Depending on how this authority is implemented, this could have really significant impacts on your practice. It means that reimbursement will be terminated during the entire course of the investigation. This will put tremendous pressure on a practice and in many cases will be enough to put them out of business. The bill currently does not give us any detail on implementation.

We will keep you aware of the regulatory developments in this area. This is a “punishment before proven guilty” type provision.

You can also expect to see litigation over the legality of this provision of the bill.

In order to avoid fraud and abuse in your practice, you may utilize our “RAC” materials posted on our web site at www.hcsiinc.com  You may sign on to the web site with your ID codes, select the “Updates/News” link on the left side of the page and scroll down to the “Medicare section to locate the RAC materials.

Stark Law Exceptions Reminder

Professional courtesy, when extended to a physician or entity who refers "designated health services" can implicate the Stark Law. The Stark Law is a strict liability statute and the penalties for violating the statute can include denial of payment, refund demands, civil monetary penalties, and exclusion from the Medicare program. The Stark ban on physician self-referral generally makes it unlawful for a physician to refer Medicare patients for radiology tests, clinical laboratory tests, physical or occupational therapy, home health care, or other such "designated health services" to an entity with which the physician has a "financial relationship".

A financial relationship can be an ownership or a compensation arrangement with an entity. A compensation arrangement is defined to include any arrangement involving any remuneration between a physician and an entity, including remuneration that is "in cash or kind". The provision of free or discounted services to a provider of "designated health services" or the provider's family would be such prohibited remuneration. There is, however, an exception to the Stark regulations to allow for certain extension of professional courtesy. In order to fall within the Stark exception, all of the following elements must be met:

·        The professional courtesy must be extended to all members of the entity's medical staff in the case of a hospital, or all members of the local community or service area, in the case of a physician practice

·        The healthcare items and services are a type routinely provided by the entity or practice

·        The professional courtesy policy must be set forth in writing and approved in advance by the entity's governing board(s)

·        The professional courtesy must not be extended to Medicare or other federal health program beneficiaries unless there is a showing of financial need, and

·        The arrangement cannot violate the anti-kickback statue or any state law