Federal statutes and regulations applicable to healthcare practitioners
sajLAW provides representation to healthcare practitioners before relevant federal regulatory agencies (including the federal Department of Health and Human Services, the federal Centers for Medicare and Medicaid Services (CMS), and the federal Department of Justice) and before the federal courts regarding matters involving federal statutes and regulations including but not limited to the following:
- False Claims Act (FCA)
- Anti-kickback statutes and regulations
- Physician self-referral prohibition statutes and regulations (Stark)
- Federal health insurance beneficiary inducement prohibition statutes and regulations
- Healthcare practitioner program participation exclusion statutes and regulations
- Health Insurance Portability and Accountability Act (HIPAA)
- Health Information Technology for Economic and Clinical Health Act (HITECH)
- Patient Protection and Affordable Care Act
1. false claims act (FCA)
- 31 U.S. Code § 3729
- The civil FCA protects the Government from being overcharged or sold shoddy goods or services.
- It is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent.
- Filing false claims may result in fines of up to three times the programs' loss plus $11,000 per claim filed.
- Under the civil FCA, each instance of an item or a service billed to Medicare or Medicaid counts as a claim, so fines can add up quickly.
- The fact that a claim results from a kickback or is made in violation of the Stark self-referral law also may render it false or fraudulent, creating liability under the civil FCA as well as the federal anti-kickback statute or the federal Stark self-referral law.
- Under the civil FCA, no specific intent to defraud is required.
- The civil FCA defines "knowing" to include not only actual knowledge but also instances in which the person acted in deliberate ignorance or reckless disregard of the truth or falsity of the information.
- The civil FCA defines "knowing" to include not only actual knowledge but also instances in which the person acted in deliberate ignorance or reckless disregard of the truth or falsity of the information.
- Further, the civil FCA contains a whistleblower provision that allows a private individual to file a lawsuit on behalf of the United States and entitles that whistleblower to a percentage of any recoveries.
- Whistleblowers could be current or ex-business partners, hospital or office staff, patients, or competitors.
- There also is a criminal FCA (18 U.S.C. § 287).
- Criminal penalties for submitting false claims include imprisonment and criminal fines.
- Physicians have gone to prison for submitting false health care claims.
- OIG also may impose administrative civil monetary penalties for false or fraudulent claims.
- Criminal penalties for submitting false claims include imprisonment and criminal fines.
(Source: United States Department of Health and Human Services, Office of Inspector General [https://oig.hhs.gov/compliance/physician-education/01laws.asp])
2. healthcare provider Anti-kickback laws
The AKS is a criminal law that prohibits the knowing and willful payment of "remuneration" to induce or reward patient referrals or the generation of business involving any item or service payable by the Federal health care programs (e.g., drugs, supplies, or health care services for Medicare or Medicaid patients). Remuneration includes anything of value and can take many forms besides cash, such as free rent, expensive hotel stays and meals, and excessive compensation for medical directorships or consultancies. In some industries, it is acceptable to reward those who refer business to you. However, in the Federal health care programs, paying for referrals is a crime. The statute covers the payers of kickbacks-those who offer or pay remuneration- as well as the recipients of kickbacks-those who solicit or receive remuneration. Each party's intent is a key element of their liability under the AKS.
Criminal penalties and administrative sanctions for violating the AKS include fines, jail terms, and exclusion from participation in the Federal health care programs. Under the CMPL, physicians who pay or accept kickbacks also face penalties of up to $50,000 per kickback plus three times the amount of the remuneration.
Criminal penalties and administrative sanctions for violating the AKS include fines, jail terms, and exclusion from participation in the Federal health care programs. Under the CMPL, physicians who pay or accept kickbacks also face penalties of up to $50,000 per kickback plus three times the amount of the remuneration.
(Source: United States Department of Health and Human Services, Office of Inspector General [https://oig.hhs.gov/compliance/physician-education/01laws.asp])
3. Physician self-referral laws (stark)
4. HEALTH INSURANCE BENEFICIARY INDUCEMENT laws
5. healthcare provider exclusion laws
6. Health Insurance Portability and Accountability Act (HIPAA)
7. Health Information Technology for Economic and Clinical Health ACT (HITECH)
8. Patient Protection and Affordable Care Act