Health Care Fraud and Abuse Compliance Manual

An immensely practical resource, Health Care Fraud and Abuse Compliance Manual provides a comprehensive overview of legislative and regulatory restrictions that affect the way health care providers conduct business and how they structure relationships among themselves. This treatise helps providers determine the boundaries of permissible conduct under the myriad statutes and regulations that relate to health care fraud and abuse at both the federal and state levels.

Specific coverage includes:

• The statutory language in the Medicare/Medicaid civil money penalties and false claims statutes
• The Medicare/Medicaid antikickback statute
• The Stark "self-referral" law
• The numerous safe harbors and exceptions contained with these prohibitions
• And more!

This authoritative resource will make you aware of your crucial obligations and options. Each chapter of the Health Care Fraud and Abuse Compliance Manual describes what the law requires, how it applies in a health care context, and what the penalties are for failure to comply.

With Health Care Fraud and Abuse Compliance Manual:

• You'll receive coverage of all the critical laws and considerations, including: false claims and fraudulent billings, civil and criminal penalties, the antikickback statute, the safe harbor regulations, the Stark Law, and state statutes
• You'll get practical advice on developing a corporate compliance program that can help you stay on the right side of the law
• You'll learn about the structures, goals, and procedures of agencies that investigate health care fraud
• You'll get an in-depth understanding of what goes into a fraud and abuse investigation - and how you can respond to an investigation to best defend your organization
• And much, much more!

Health Care Fraud and Abuse Compliance Manual has been updated to include:

• Updated nationwide health care fraud and abuse enforcement statistics
• OIG Work Plan for FY 12 (Medicaid projects)
• Enforcement actions involving billing for services of unlicensed personnel
• Enforcement actions involving billing without proper documentation
• Enforcement actions involving illegal inducements to beneficiaries
• Hospital liability for submission of false cost reports
• Cases involving maximum hospital liability for EMTALA violations
• Criminal false claims liability for unsolicited telemarketing by a DME supplier
• Managed care provider liability for cherry-picking, retaining overpayments, and other practices
• Hospice liability for providing services to ineligible patients
• Pharmaceutical manufacturer liability for pricing-related false claims violations
• Enforcement actions involving federal research grant fraud
• Criminal kickback liability for sham consulting arrangements
• Self-referral liability for office lease agreements and independent contractor relationships inconsistent with fair market value or not memorialized in writing
• Updated Medicaid Fraud Control Unit performance standards (MFCU)
• False claims laws of Massachusetts, Montana, and Nevada
• OIG evaluation of Massachusetts, Montana, and Nevada false claims laws

• Overview of Health Care Fraud and Abuse
  • Summary of Health Fraud Offenses and Sanctions
  • Government Enforcement Programs and Trends
• False Claims and Fraudulent Billing
  • Criminal Penalties for False Statements, False Claims, and Other Fraudulent Billing Activities
  • Civil Penalties for False Statements, False Claims, and Other Fraudulent Activities
  • Risks of Potential Civil and Criminal Liability
  • Exclusion from Federal and State Health Care Programs
  • Double Jeopardy and Excessive Fines
• Fraud and Abuse Prohibitions under the Antikickback Statute
  • The Antikickback Statute
  • Provider Risks under the Antikickback Statute
  • Safe Harbor Regulations
  • Sanctions
  • Attorney Involvement in Antikickback Arrangements
• Federal Physician Self-Referral Prohibitions: The Stark Law
  • History of the Law and Regulations
  • Self-Referral Provisions
  • Sanctions and Enforcement
  • Reporting Requirements
  • Distinction Between Antikickback and Self-Referral Legislation
  • Advisory Opinions under the Stark Law
  • Provider Risk Areas and Risk Avoidance
  • Administrative Action and Judicial Interpretations
• Corporate Compliance Programs
  • Liability for Corporate Offenses
  • The Guidelines and Corporate Compliance Programs
  • Developing a Compliance Program
  • Benefits of a Compliance Program
• Anatomy of an Investigation
  • Investigators of Health Care Fraud
  • Investigative Tools
  • Investigatory Strategies
  • Origins of an Investigation
  • Strategies for Responding to a Subpoena
  • How to Deal with Investigators
  • Attorney-Client Privileges and Others
  • Specific Defenses to Investigative Methods Used in Health Care Fraud
  • Internal Investigations
  • Managing Documents
  • Medical Records
  • Anticipating Health Care Fraud Investigations
  • Provider Disclosures
  • The Settlement Process
• Report on State Antifraud Enforcement
  • State Medicaid Fraud Control Units
  • Fraud and Abuse in Medicaid Managed Care
  • State Medicaid Agency Fraud and Abuse Plan
  • State False Claims Acts
  • State Health Care False Claims Statutes
  • State Self-Referral and Antikickback Laws
  • Future Trends in Fraud Enforcement