Issue link: https://blog.providence.org/i/1541294
Medicare with a total value of $39,313,065. The district court assessed 21,730 civil False Claims Act penalties. Ultimately, the hospital was on the hook for $119,515,000 in False Claims. Deliberate Ignorance: You do not have to intend to defraud the Government to violate the False Claims Act. You can be punished if you act with deliberate ignorance or reckless disregard of the truth. Accurate Coding and Billing: Forms of medical billing fraud include duplicate billing, phantom billing, upcoding, under coding, medical equipment fraud and billing separately for services already included in a global fee. Accurate medical records are critical. The Medicare and Medicaid programs may review the patient's medical records to verify the claim, as well as the quality of care. If the medical record does not support the claimed service, the claim may be denied. Good Documentation: Good documentation helps ensure quality patient care. It is also a quality of care issue. It helps ensure that your patients get the best possible clinical care from you and other providers who may rely on your records. If you have questions about coding and documentation, ask someone you trust. Anti-Kickback Statute (AKS) The AKS is a federal criminal law and applies to both payers and recipients of kickbacks. The law prohibits obvious kickbacks, like cash for referrals, as well as more subtle kickbacks, like free rent, below fair market value rent, free clerical staff or excessive compensation for medical directorships. As a result, violation of the AKS is a felony punishable by a maximum fine of $100,000, imprisonment up to 10 years or both. Conviction also will lead to mandatory exclusion from Federal health care programs, including Medicare and Medicaid. Violation of the AKS also triggers liability under the Civil Monetary Penalties Law (CMPL). The CMPL carries penalties of up to $50,000 per kickback, in addition to three times the amount of the remuneration. It also makes the resulting bills to the government false under the False Claims Act. As a result, the violator is responsible for three times the value of the bills, and a False Claims Act Penalty of up to $27,894 per bill. Numerous physicians have been sanctioned under the False Claims Act by the Justice Department or by private individuals in a qui tam proceeding for selling their product loyalty to drug or device companies or other vendors. Physician Self-Referral Law [42 U.S.C. § 1395nn] Commonly referred to as the Stark Law Prohibits physicians from referring patients to receive "designated health services" payable by Medicare or Medicaid from entities with which the physician or an immediate family member has a financial relationship, unless an exception applies. • Financial relationships include both ownership/investment interests and compensation arrangements. For example: If you invest in an imaging center, the Stark law requires the resulting financial relationship to fit within an exception or you may not refer patients to the facility and the entity may not bill for the referred imaging services. • "Designated health services" include clinical laboratory services, physical therapy and home health services, among others. Exclusion from Medicare and Medicaid Healthcare agencies that do business with excluded individuals, entities or partners on these lists may be subject to penalties, fines or civil monetary penalties (CMP) and possible suspensions from participation in government health care programs. Mandatory exclusions Imposed on the basis of certain criminal convictions. Provider Education Training Manual 29 |