1. There are five federal laws governing potential fraud and abuse by physician practices: Name them.
2. Pick one of the five statutes and explain how it works in 2-3 sentences.
3. What are three examples of businesses in which physicians are often invited to invest? Explain the examples/
4. Why is it illegal for a physician to make certain in vestments in health care-related businesses?
Chapter 16
Physician Practices
Learning Objectives
Familiarity with fraud & abuse laws
Practice activities affected by the laws
Content of multi-step compliance program
Compliance in practices with limited resources
Creating & implementing a compliance program in a physician practice
High risk areas of a physician practice
Compliance officer, records retention, and lines of communication
Introduction
Despite their wide range of size and complexity, all physician practices must have an operational compliance program.
It is the best way to avoid serious legal problems, and it is now mandatory.
Sources of Compliance Obligation
Compliance programs required because of the numerous federal laws on fraud and abuse targeted at health care organizations.
False Claims Act
Anti-Kickback Statute
Physician Self-Referral Law (“Stark” law)
Exclusion Statute
Civil Monetary Penalties Law
Licensing, Certification, and Credentialing
Accreditation
Fraud and Abuse Laws Applied to Physician Practices (I)
Practice Relationships/Interactions/Dealings With Other Health Care Providers:
Physician investments in health care-related businesses
Physician recruitment
Fraud and Abuse Laws Applied to Physician Practices (II)
Physician Relationships/Interactions/Dealings With External Vendors:
Free samples
Physician-industry collaboration
Open physician-industry relationships
Conflict of interest disclosure
Fraud and Abuse Laws Applied to Physician Practices (III)
Physician Relationships/Interactions/Dealings With Payors
Coding and billing
Documentation of services provided
Enrollment with CMS as a health care provider
Authority to prescribe controlled substances
Acceptance of Medicare assignment.
7
Compliance Programs for Individual and Small Physician Practices
Conduct internal monitoring and auditing.
Implement compliance and practice standards.
Designate a compliance officer or contact.
Conduct appropriate training and education.
Respond to detected offenses and develop corrective action.
Open lines of communication with employees.
Enforce disciplinary standards through guidelines.
Features of Compliance in
Physician Practices
Compliance Programs are Mandatory, Not Voluntary
Benefits of a Voluntary Compliance Program
Innocent Errors Are Not Intentional Fraud
Multi-Step Compliance Program (I)
Step One – Auditing and Monitoring
Standards and procedures review
Claims submission audit
Step Two – Establish Practice Standards and Procedures
Coding and billing
Reasonable and necessary services
Documentation
Improper inducements, kickbacks, and self-referrals
Retention of records
Multi-Step Compliance Program (II)
Step Three – Designation of a Compliance Officer
Step Four – Conducting Appropriate Training and Education
Compliance training
Coding and billing training
Multi-Step Compliance Program (III)
Step Five – Responding to Detected Offenses and Developing Corrective Action Plans
Step Six – Developing Open Lines of Communication
Step Seven – Enforcing Disciplinary Standards Through Well-Publicized Guidelines
Questions???
