Fraud and Abuse - Regulatory Compliance

Overview

As the healthcare industry continues to see unprecedented regulation, we work to keep our clients out of the headlines and in compliance with today's regulatory and statutory requirements, including the Federal Physician Self-Referral Law (the “Stark Law”), the Federal Anti-Kickback Statute, state “mini” Stark and Anti-kickback Statutes, as well as the Federal False Claims Act, and the Emergency Medical Treatment And Labor Act (“EMTALA”), among others.

Healthcare providers regularly engage in business arrangements that may implicate the fraud and abuse laws. BakerHostetler has experience in the breadth of fraud and abuse matters, from analyzing a potential new business arrangement to reviewing ongoing compliance and assisting clients with handling a self-disclosure or government investigations. We understand that our clients are facing increased pressures from various enforcement agencies and we help them navigate expectation of self-governance in the increasingly regulated healthcare environment. Our clients have included hospitals and health systems, physician groups, laboratories, imaging centers and post-acute providers, such as home health agencies and DME suppliers.

Compliance programs

Our national team works with clients to establish proactive compliance and auditing programs to place them in the best position to prevent, identify and deter violations of the fraud and abuse laws. Should a potential violation arise, we have found that a comprehensive, tailored compliance program can be persuasive in avoiding enforcement proceedings or receiving less severe penalties.

We routinely advise clients, their boards, management, compliance committees and officers on the changing needs and requirements of providers and others in the healthcare industry. Our experience includes establishing or refining corporate compliance programs tailored to a specific organization’s needs, while at the same time meeting or exceeding official guidance published by state and federal authorities concerning comprehensive compliance programs. Our attorneys, several of whom include former U.S. Department of Justice healthcare prosecutors, have a first-hand understanding of the government’s analysis of an “effective” compliance program and work to ensure that our clients’ compliance programs and initiatives are designed as such.

We routinely conduct internal audits and address internal compliance issues, assist in voluntary disclosure of overpayments and respond to government inquiries and investigations. Our team’s knowledge in reimbursement, fraud and abuse compliance and corporate governance inform our approach to assessing compliance risks. We see beyond the horizon to help clients minimize the legal, economic and reputation risks posed by compliance and governance oversight matters.

Select Experience

  • Provide general Stark Law, Anti-kickback, and fraud and abuse advice to hospitals and other healthcare providers regarding structuring compliant relationships with physicians and other referral sources, including contractual relationships, such as leases and employment and medical director agreements
  • Assist in internal and external investigations and regulatory compliance activities related to reimbursement, including evaluation and management coding, supervision and coverage requirements related to ancillary services and mid-level providers, and Stark Law and state anti-kickback laws
  • Provide general fraud and abuse advice to healthcare providers regarding structuring compliant relationships with beneficiaries relating to various issues, including the provision of discount cards, complementary local transportation, conducting health fairs and deductible and copayment issues
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Experience

  • Provide general Stark Law, Anti-kickback, and fraud and abuse advice to hospitals and other healthcare providers regarding structuring compliant relationships with physicians and other referral sources, including contractual relationships, such as leases and employment and medical director agreements
  • Assist in internal and external investigations and regulatory compliance activities related to reimbursement, including evaluation and management coding, supervision and coverage requirements related to ancillary services and mid-level providers, and Stark Law and state anti-kickback laws
  • Provide general fraud and abuse advice to healthcare providers regarding structuring compliant relationships with beneficiaries relating to various issues, including the provision of discount cards, complementary local transportation, conducting health fairs and deductible and copayment issues
  • Represent providers in self-disclosures related to overpayments and Stark Law violations
  • Represent hospitals and physicians in compliance matters related to illegal remuneration, Stark Law and Civil Monetary Penalty Law issues
  • Represent various healthcare entities in the development and implementation of corporate compliance plans, including plan design, risk assessments, internal reviews, self-audits, voluntary disclosures and repayments to governmental and private health programs
  • Provide compliance training on fraud and abuse laws, policies and procedures and medical record documentation
  • Represent providers in internal compliance audits of billings and related self-disclosure of various departments
  • Represent hospitals, health systems and physician groups in internal investigations involving concerns of incorrect billing and coding

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