Category Archives: Fraud & Abuse & False Claims Act

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Inpatient or Outpatient Surgery: False Claims or Legitimate Difference in Medical Judgment?

It can be financially costly for hospitals to submit claims for inpatient surgical procedures which can be performed safely and effectively as an outpatient procedure.

The Department of Justice recently announced a settlement in which 55 hospitals in 21 states agreed to pay a total of $34 million for performing kyphoplasty procedures on an inpatient basis rather than as an … Continue Reading

Tuomey Standing Firm in Face of “Stark” Penalties

The next round in United States ex. rel. Drakeford v. Tuomey Healthcare System, Inc., is underway and Tuomey Healthcare keeps fighting.  As previously reported, on May 8, 2013, a federal jury found that Tuomey Healthcare System, a non-profit system in South Carolina, violated the Stark law and the False Claims Act in connection with its compensation structure for … Continue Reading

Second Time Around Tuomey Healthcare System is Found to Have Violated Stark Law and False Claims Act; Faces Penalties of up to $357 Million

In the ongoing saga of U.S. ex. rel. Drakeford v. Tuomey Healthcare System, Inc., on May 8, 2013, a South Carolina jury found that Tuomey violated the Stark Law and the False Claims Act.  The jury determined that Tuomey submitted over 21,000 improper claims, totaling $39 million. When penalties and treble damages of up to $11,000 per claim are … Continue Reading

Staying Out of the Principal’s Office: The OIG Revamps the Provider Self Disclosure Protocol

Introduction:

I have a vivid memory of sitting next to my father in an elementary school principal’s office.  The facts were: (1) three “student of the week” ice cream vouchers had gone missing from my teacher’s desk; (2) I was a somewhat portly child; and (3) I had tried, albeit unsuccessfully, to cash in one of those illicit vouchers at … Continue Reading

CMS Proposes Changes to Electronic Medical Records Rules

I. Overview:

The Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services’ (OIG) have issued a pair of proposed rules (see CMS rule, OIG rule) that seek to revise the current Electronic Health Records exceptions to the Physician Self-Referral (Stark) and Anti-Kickback laws.

The proposed rules would amend the current … Continue Reading

Regulatory Roulette: How Much Will A Violation Of The Healthcare Statutes Cost You? The Answer Is Not Always Clear

Two healthcare cases announced during the first week of April, 2013, vividly illustrate the uncertainty of how much a violation of applicable healthcare statutes or regulations might cost a provider.

On April 3, 2013, the Department of Justice announced that Intermountain Health Care, Inc., which operates the largest health system in Utah, had agreed to pay the United States … Continue Reading

New OIG Special Fraud Alert Declares PODs To Be “Inherently Suspect”

On March 26, 2013, the Department of Health and Human Services Office of Inspector General (OIG) issued a Special Fraud Alert advising that the OIG considers physician-owned distributorships (“PODs”) as “inherently suspect” under the federal Anti-Kickback Statute. In the strongly worded guidance, the OIG defines PODs as physician-owned entities that sell or arrange for the sale of implantable medical devices … Continue Reading

Recent Criminal and Civil Enforcement Actions

In 2009, the Health Care Fraud Prevention and Enforcement Action Team (“HEAT”) initiative was formed as a joint effort between the Departments of Justice and Health and Human Services, and combating health care fraud continues to be a major focus of federal and state authorities. The Office of Inspector General (“OIG”) publishes a list of the criminal and civil enforcement … Continue Reading

Court Determines Whether Marketing Rep Was Really a Bona Fide Employee

In January, a Federal District Court in Oklahoma issued a ruling in favor of a former marketing representative of a medical equipment distributor.  The Court determined that Gary Weaver was, in fact, engaged on an independent contractor basis, not as an employee, and therefore his employment agreement with Joint Technology, Inc. was an unenforceable illegal contract under the Federal Anti-Kickback

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Controlling Healthcare Costs-A New Direction

Historically, federal and state regulations designed to control healthcare costs have focused on preventing fraud and abuse and self-referrals. Prior to adoption of the Patient Protection and Affordable Care Act in 2010, the Anti-Kickback Statute and the Stark Law were probably the most frequently referenced healthcare statutes.  Both of these statutes, which have been in effect for more than 20 … Continue Reading

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