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Each week you will write and submit a brief summary of the important concepts learned during the week. The summary will include a summary of the instructor’s weekly lecture including any videos included in the lecture.

Chapter 17
Regulatory and Design Issues
for an Effective Physician Practice
Compliance Program
Summary of Fraud and Abuse Laws
• Federal Criminal Statutes:
1. Health Care Fraud (18 U.S.C. Section 1347)
• It is a crime to:
–Knowingly and willfully execute (or
attempt to execute) a scheme to defraud
any healthcare benefit program,
–or to obtain money or property from a
healthcare benefit program through a
false representation.
Summary of Fraud and Abuse Laws
• Conduct giving rise to liability:
– Billing for services never provided to
patients
– Up-coding: billing for more extensive
services than were actually rendered
– Falsely certifying that services were
medically necessary
Summary of Fraud and Abuse Laws
• Conduct giving rise to liability:
– Unbundling: billing for each component of
the service instead of an all-inclusive code
– Billing for non-covered services as if covered
– Flagrant and persistent overutilization of
medical services with little or no regard for
results, the patient’s ailments, condition, or
medical needs.
Summary of Fraud and Abuse Laws
• False Statements Relating to Health Care
Matters (18 U.S.C. Section 1035)
-It is a crime to
• Knowingly and willfully falsify or
conceal a material fact;
• Make any materially false statement;
Summary of Fraud and Abuse Laws
• False Statements Relating to Health Care
Matters (18 U.S.C. Section 1035)
-It is a crime to (continued)
• Or use any materially false, fictitious, or
fraudulent writing or document in
connection with the delivery of or
payment for healthcare benefits, items, or
services.
Summary of Fraud and Abuse Laws
• Theft & Embezzlement in Connection with
Health Care Benefit Program 18 (U.S.C.
Section 669)
– It is a crime to:
• Knowingly and willfully embezzle, steal,
or intentionally misapply any assets of a
healthcare benefit program.
Summary of Fraud and Abuse Laws
• False Claims Act (18 U.S.C. Section 287)
– Prohibits the presenting of a claim to the
U.S.
– That the claimant knows to be “false,
fictitious, or fraudulent”
Summary of Fraud and Abuse Laws
• Mail & Wire Fraud (18 U.S.C. Sections 1341
and 1343)
– The mail and wire fraud statutes cover the
entire range of fraudulent conduct for:
• Using the mails to send or receive
payments
• Explanation of benefit forms
• Other related documents
Summary of Fraud and Abuse Laws
• Medicare & Medicaid Patient Protection Act
of 1987 (42 U.S.C. Section 1320a-7b(a))
– Six specific types of conduct prohibited:
1. Making false statements
2. Concealment of information with intent
to induce improper payments
3. Improperly converting federal payments
Summary of Fraud and Abuse Laws
• Medicare & Medicaid Patient Protection Act
– Six specific types of conduct prohibited:
4. Submitting claims for services provided
by unlicensed individuals
5. Misrepresenting services actually
rendered
6. Falsely certifying that certain services
were medically necessary.
Summary of Fraud and Abuse Laws
• Obstruction of Criminal Investigations of
Health Care Offenses (18 U.S.C Section 1518)
– Prohibits the obstruction of a criminal
investigation in any material way
– Such as by failing to produce subpoenaed
records, destroying or altering records, or
attempting to influence the testimony of an
employee questioned by government
investigators.
Summary of Fraud and Abuse Laws
• Anti-kickback Statute (42 U.S.C. Section
1320a-7(b))
– Provides criminal and civil penalties
– For certain business arrangements that are
influenced by the referral of patients for
healthcare services covered by a federal
healthcare program, such as Medicare and
Medicaid.
Summary of Fraud and Abuse Laws
• State Criminal Laws:
– States also have false healthcare claims
statutes that prohibit the submission of
fraudulent bills to private health insurers.
– Statutes prohibit the solicitation or receipt or
any “bribe or rebate” in connection with a
private healthcare entity.
Summary of Fraud and Abuse Laws
• Civil & Administrative Statutes:
– To establish liability under the civil False Claims
Act (FCA), the government must establish:
1. The provider presented or caused to be
presented to an agent of the U.S. a claim for
payment,
2. The claim was false or fraudulent, and
3. The defendant knew that the claim was false
or fraudulent.
Summary of Fraud and Abuse Laws
• Each individual false claim submitted to
Medicare or Medicaid gives rise to potential
penalties between $5500 and $11,000, coupled
with treble damages.
Summary of Fraud and Abuse Laws
• Federal Physician Self-Referral Prohibitions
(The Stark Law):
– Prohibits a physician from referring a
Medicare or Medicaid patient for
“designated health services” in which the
physician (or immediate family member)
has an ownership or investment interest or
compensation relationship.
Identified Physician Compliance
Risk Areas
• Risk areas focused on during physician
investigations:
– Coding and Billing
– Reasonable and Necessary Services
– Documentation
– Improper Inducements, Kickbacks, and SelfReferrals
Formal Integration of
the Compliance Program
• Compliance Counsel:
– A group practice should seek and identify its
compliance counsel and other advisors.
– The attorney should not be the same as the
one used for routine legal matters.
Chapter 18
Implementing and Operating a
Physician Practice Compliance Program
The Compliance Plan Within the
Context of a Physician Practice
• Delegation, Responsibility, and Authority:
– Management involves working with and
delegating functional tasks and
responsibilities to other people in an
organization to achieve the objectives of the
organization.
The Compliance Plan Within the
Context of a Physician Practice
• Delegation, Responsibility, and Authority:
– If the amount of authority delegated is not
commensurate with the level of
responsibility, the ability to execute the
tasks necessary to achieve the goals of the
organization is hampered.
The Compliance Plan Within the
Context of a Physician Practice
• Planning, Controlling, Evaluation, and
Feedback
• Planning:
– Three levels of planning
Planning
1.
Strategic: Typically has a 5-year analytical
horizon and includes the following.
– Market research
– Analysis of competition
– Market needs and trends
– Assessment of opportunities and market
threats
– Evaluation of the strengths and
weaknesses of the organization
Planning
2. Long-Term Planning: Typically has a shorter
time horizon (not less than 1 year, no more
than 4 years).
–Identifies financial and performance
objectives
–Identifies human and physical resources.
Planning
3. Operational Planning: Typically has the
shortest time frame (less than 1 year)
– Assigns tasks to designated personnel
– Budgets
– Production timetables
The Compliance Plan Within the
Context of a Physician Practice
• Controlling:
– Those policies and procedures that:
• Ensure the efficient use of resources
• Involve the development of standards
• Institute methods for motivating
employees
• Solve operational problems
The Compliance Plan Within the
Context of a Physician Practice
• Evaluation and Feedback:
– Qualitative and quantitative methods for
assessing whether the procedures and
controls that have been established have
resulted in the achievement of the program’s
goals.
The Compliance Plan Within the
Context of a Physician Practice
• Human Resources Management:
– Typically encompasses six functions:
1. Human resources planning
–Job analysis and job descriptions
–Staffing levels
–Job evaluation
The Compliance Plan Within the
Context of a Physician Practice
• Human Resources Management:
2. Employment
–Identifying sources to recruit new
candidates
–Interviewing, testing, and performing
reference checks on prospective
candidates
The Compliance Plan Within the
Context of a Physician Practice
• Human Resources Management:
3. Induction and orientation
–Design of staff orientation programs
–Processing of benefits
4. Training and development
–Training of management in
management and motivational skills
The Compliance Plan Within the
Context of a Physician Practice
• Human Resources Management:
5. Employee training and development
–Training of management in management
and motivational skills
6. Health and safety
–Physical examinations
–Occupational Safety and Health
Administration (OSHA) requirements
The Elements of
Compliance Plans and Programs
• Evaluating the Size of a Practice:
– Key determinants to consider:
• Total practice revenues
• Medicare receipts
• Operational expenses
• Number of physicians and support staff
• Organizational complexity
The Elements of
Compliance Plans and Programs
• Seven elements to address the management
issues:
1. Standards of conduct & policies and
procedures
2. Designation of a compliance officer
3. Conducting effective training
4. Effective lines of communication
The Elements of
Compliance Plans and Programs
• Seven elements to address the management
issues: (continued)
5. Auditing and monitoring
6. Establishing disciplinary guidelines
7. Responding to detected offenses and
developing corrective action initiatives
A Planning and Implementation
Work Plan
• The general work plan outlines a broad
approach that the user can supplement with
task detail.
• Tasks should be committed to a Gantt chart.
• These types of task and check-off lists:
– Identify the tasks and subtasks that are
required to accomplish a particular project
A Planning and Implementation
Work Plan
• These types of task and check-off lists:
– Assign tasks to individuals with
responsibility for those tasks
– Estimate the number of calendar days,
weeks, or months that may be necessary for
implementation

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