Articles Posted in Medicare Fraud

223220955_d39c2ebad0_b-e1642805878743Many of our healthcare and business law firm’s clients are in the business of renting expensive medical equipment for use by medical practices.  Generally, these arrangements raise compliance questions under the Physician Self-Referral Act, referred to as Stark Law, and the Anti-Kickback Statute (“AKS”).  Should a regulator find an arrangement violates either law, the consequences are severe.  The perhaps unfortunate truth is that rarely can a sincere and analytical attorney tell you with confidence that an arrangement does or does not violate either law.  The analysis usually places an arrangement on a scale of low to high risk of noncompliance.  To assist in understanding whether an arrangement complies with Stark Law and AKS, the rules provide specific exceptions and safe harbors, respectively.  Both Stark Law’s exceptions and AKS’s safe harbors outline ways in which an equipment rental agreement may satisfy the protections.  One question that frequently arises with our clients is whether they can structure an equipment rental agreement to have a per-use (often called a “per-click”) payment term, wherein there is no set monthly amount but, rather, the lessee pays the lessor a predetermined amount for each time the equipment is used.

In this blog post, we outline the basic rules for equipment rental agreements under AKS and whether per-click payment terms satisfy AKS’s Equipment Rental safe harbor. Continue reading ›

iStock_000033418316_Medium-e1626470315777Many of our healthcare and business law firm’s clients are in the business of renting expensive medical equipment for use by medical practices.  Generally, these arrangements raise compliance questions under the Physician Self-Referral Act, referred to as Stark Law, and the Anti-Kickback Statute (“AKS”).  Should a regulator find an arrangement violates either law, the consequences are severe.  The perhaps unfortunate truth is that rarely can a sincere and analytical attorney tell you with confidence that an arrangement does or does not violate either law.  The analysis usually places an arrangement on a scale of low to high risk of noncompliance.  To assist in understanding whether an arrangement complies with Stark Law and AKS, the rules provide specific exceptions and safe harbors, respectively.  Both Stark Law’s exceptions AKS’s safe harbors outline ways in which an equipment rental agreement may satisfy the protections.  One question that frequently arises with our clients is whether they can structure an equipment rental agreement to have a per-use (often called a “per-click”) payment term, wherein there is no set monthly amount but, rather, the lessee pays the lessor a predetermined amount for each time the equipment is used.

In this blog post, we outline the basis rules for equipment rental agreements under Stark Law and whether per-click payment terms may satisfy Stark Law’s Rental of Equipment exception.  Our next post will analyze the same question under AKS.  If you have questions regarding this blog post or wish to evaluate the risks in your equipment lease arrangement, you may contact us at (404) 685-1662 (Atlanta) or (706) 722-7886 (Augusta), or by email, info@hamillittle.com. You may also learn more about our law firm by visiting www.hamillittle.com.

Continue reading ›

About 20% of United States tax dollars are spent on heathcare.  Naturally, reducing improper payments has been a priority of CMS. Thus, all medical practice managers and healthcare providers should be aware of CMS’s process of contracting with Uniform Program Integrity Contractors (UPIC’s), private entities hired by CMS Health-Audit-300x200to audit providers suspected of fraud. UPIC contracts combine Zone Program Integrity Contractors (ZPIC’s) and Medicaid Integrity Contractors (MIC’s) to coordinate Medicare and Medicaid auditing. UPIC’s focus primarily on Medicare claims, and seek to distinguish between provider billing errors or fraud.

UPIC Audit Lawyers

Our business and healthcare law firm follows legal trends in the healthcare industry.  UPIC’s are private sector organizations that review Medicare claims in order to assist the government in recovering overpayments to healthcare providers.  UPIC audits are often generated through data analysis or by review of consumer complaints and most often target specific healthcare providers. UPIC’s conduct screening, medical reviews, and investigations, while also implementing remedies and collaborating with state and local governments to ensure compliance with payment guidelines. UPIC’s are organized regionally, with Georgia and South Carolina falling in District 4 and managed by Safeguard Services.  In recent years, home health agencies, DME companies, therapy clinics, and laboratories have been targets for fraud investigations through extensive audits.

080919014456-e1583356935491
In a landmark federal False Claims Act case closely watched for many years by hospice administrators, other healthcare providers and legal experts, last week the Department of Justice (DOJ) entered a joint dismissal in settlement of the case against AseraCare Inc., a national hospice provider company.  The settlement marks an effective win for the defendants, in that the government agreed to accept repayment of $1 million, reduced from its initial demand of more than $200 million. https://www.businesswire.com/news/home/20200227005767/en/

Georgia-based Healthcare Reimbursement and Compliance Attorneys

Allegations in the case were brought initially between 2008 – 2010 by several former employees of AseraCare and the Department of Justice, alleging that AseraCare had submitted false claims to Medicare for patients who were arguably not terminally ill, and thus ineligible for hospice benefits, placing pressure on employees to enroll more patients using questionable recruitment practices – including targeting near-death patients so that length of stay numbers were kept low.

medical-doctor-1314902-mAs technology improves the ability for providers to communicate, existing healthcare laws will continue to be put to the test. Now, a new call for care coordination is driving quality improvement initiatives for physicians and hospitals. In 2018, U.S. Department of Health and Human Services (HHS) launched its initiative “Regulatory Sprint to Coordinated Care,” to facilitate value-based healthcare and promote effective communication strategies between physicians. The Regulatory Sprint seeks to increase a patient’s ability to understand their treatment plan, promote coordination between providers, establish incentives for providers to coordinate efficient care, and encourage information-sharing between providers and facilities.

Healthcare Fraud and Abuse Lawyers

The initiative highlights the importance of removing the barriers created by four federal healthcare laws: the Physician Self-Referral Law; the Federal Anti-Kickback Statute; the Health Insurance Portability and Accountability Act (HIPAA); and substance-disorder treatment rules stemming from 42 CFR Part 2. Previously, critics have claimed that the monetary penalty provisions within the statutes prevent providers from being able to adequately coordinate care. In response, HHS has proposed Stark Law and Anti-Kickback reforms.

Continue reading ›

1066058_patrol_hat_too1Healthcare fraud attributable to nurses, hospitals, pharmacists, equipment providers and doctors, contributes to the high cost of medical care. For this and other reasons, fraud continues to be a hot topic in the healthcare industry. Recently, there have been numerous headlines regarding Medicare, Medicaid, and private insurance company investigations of providers for improper billing practices. Accusations stem from both whistleblowers and audits, making it difficult for providers to hide behind fraudulent billing practices. With numerous investigations in the spotlight in recent months, providers should be alert and act to ensure that they are compliant with the law.

Continue reading ›

medical-doctor-1314903-mLegislation controlling self-referrals has created a complex road map that can leave doctors with questions regarding their ability to use business agreements to promote lab work and advanced imaging technology for their patients. For physicians, the rules and regulations of self-referrals for imaging can create headaches and lead to fines.

Georgia Physician Self-Referral and Fraud and Abuse Lawyers

Physician self-referrals may create conflicts of interest and can potentially result in violations of federal or state law. Previously, providers only had to worry about referrals for patients with federal insurance plans. However, the new legislative trend is expanding their liability. Physicians recently have been prosecuted for kickbacks involving patients with commercial insurance plans as well. If a physician’s referral is determined to be guided by profit and not the patient’s best interest, that referral could be violating the law.

Continue reading ›

balance-1172800-1-300x204This month, the abrupt closing of four Tennessee pain management clinics under investigation for state and federal health insurance fraud made headlines.  Those clinics, formerly affiliated with PainMD and rebranded as Rinova, closed last week.  Federal authorities alleged that PainMD and its parent company inflated profits by providing patients with unnecessary injections to be paid by federal health insurance programs.  Authorities of the state of Tennessee initiated their own investigation, with concerns that the conduct of clinic personnel may violate state law.

Georgia Pain Management and DEA Defense Law Firm

In the PainMD pain clinic investigations, not only were the companies and clinic administrators at risk for financial penalties and reputational harm in connection with potential fraud, but so were the health providers who worked at those clinics.  Three PainMD nurses were indicted on federal charges in connection with procedures provided at the Tennessee clinics under investigation.

Continue reading ›

pill-shadows-1200049The exposure and concern surrounding the opioid epidemic is at an all time high. Notwithstanding the urgency of the issue itself, this publicity places increased pressure on the intervening parties—sub-agencies of the Department of Health and Human Services, Department of Justice (DOJ) and state Attorney’s General—to implement regimens that make a difference.  Our Georgia-based business and healthcare law firm follows developments that impact pain management physicians and medical practices.

At the Federal level, the DOJ is focused on taking steps to strategically intervene into physicians and pharmacies. Accordingly, the DOJ has expanded its enforcement to release a new tactic in the form of temporary restraining orders (TRO) against pharmacies that have violated the False Claims Act and the Controlled Substances Act. This tactic proved successful in a Tennessee District Court on January 13, 2019.

Continue reading ›

US-SUP-CTThe highly anticipated “AseraCare” decision (United States v. GGSNC Admin. Serv. LLC) is still pending before the Eleventh Circuit Court of Appeals. The court is considering “whether a mere difference of opinion between physicians, without more, is enough to establish falsity under the False Claims Act.” To provide some context, the U.S. District Court evaluated the “falsity” element of the False Claims Act in the context of a hospice provider’s “clinical judgment” that a person meets the standard to be eligible for the Medicare Hospice Benefit. The requirement is that a patient be eligible for Medicare Part A and be “Terminally Ill” as defined by the regulation. “Terminally Ill” requires that the hospice Medical Director make a determination that the prognosis of the patient indicates a life expectancy of 6 months or less. So the issue is whether or not the “battle of expert opinion,” without some additional element, is enough to establish that a patient is not terminally ill rendering the subsequent Medicare reimbursement submissions false or fraudulent.

Continue reading ›

Contact Information