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Laws Governing Healthcare Compliance

The healthcare environment is changing fast in the United States. Steering clear of compliance violations is key to maintaining the health of your patients — and your practice.

In early April, a federal grand jury delivered a 59-count indictment implicating 10 Florida residents for participating in a scheme to defraud Medicare through submitting false claims and receiving kickbacks.

Our law firm is available to work with physicians, physicians groups and non-profits providing medical services to ensure their understanding of primary fraud laws, both state and federal, as well as the fine-grained compliance issues associated with them. The primary federal fraud laws that apply to healthcare providers include:

  • Anti-Kickback Statute: In many businesses, there are rewards to those who refer clients or buyers to another business. In the healthcare industry, the Anti-Kickback is a criminal law that prohibits physicians from receiving rewards, payments or other forms of value for the referral of patients in federal health care programs.
  • Physician Self-Referral Law: The Stark Law is a civil law that prohibits physicians or medical groups from referring patients to other practices or service centers in which they have a financial interest.
  • False Claims Act: The False Claims Act is designed to protect the federal government from being overcharged for goods or services, including fraudulent charges to Medicare and Medicaid. Healthcare providers who bill or process claims they know to be fraudulent violate the False Claims Act. A violation of the Anti-Kickback Statute or the Stark Law may also form the basis of a False Claims Act claim. The False Claims Act also has a whistleblower provision that allows private individuals to file a lawsuit on behalf of the federal government and allowing the whistleblower to retain a percentage of any recovery.

One cannot underscore the importance of complying with federal and state laws, and understanding that falling within a safe harbor under one federal law may constitute a violation of another law. The ramifications of violating these laws are very serious:

  • Criminal penalties: A violation of the Anti-Kickback Law can be punished by imposition of criminal penalties, including imposition of fines, incarceration and exclusion from federal healthcare programs.
  • Civil penalties: fines, damages and exclusion. Large civil penalties may be imposed for the violation of the Stark Law, including penalties of up to $15,000 per service provided, penalties of up to $100,000 for any “circumvention schemes,” disallowance of billing, a requirement that funds be repaid to Medicare, and denial of payment by Medicare.  Actions for monetary fines or damages consequent to violations of either the Anti-Kickback Statute or Stark Law may be brought by the federal government or by whistleblowers on behalf of the United States government pursuant to the False Claims Act.  Even in the absence of a criminal conviction of the Anti-Kickback Statute, the Office of Inspector General (OIG) may also exclude physicians from federal health programs.   

With the development of health information exchanges, bundling of services and other administrative changes in the delivery of modern healthcare, compliance issues are bound to rise. When you need guidance about a compliance issue, healthcare contract or a regulatory issue related to your practice in Florida, speak with a healthcare attorney in Jacksonville.


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