Presenting a live 90-minute webinar with interactive Q&A Healthcare Fraud: Identifying and Assessing Fraud Risks, Implications of Current Enforcement, Ensuring Compliance THURSDAY, JUNE 9, 2016 1pm Eastern | 12pm Central | 11am Mountain | 10am Pacific Today’s faculty features: Benjamin J. Fenton, Partner, Fenton Law Group , Los Angeles Matthew M. Curley, Member, Bass Berry & Sims , Nashville, Tenn. The audio portion of the conference may be accessed via the telephone or by using your computer's speakers. Please refer to the instructions emailed to registrants for additional information. If you have any questions, please contact Customer Service at 1-800-926-7926 ext. 10 .
Tips for Optimal Quality FOR LIVE EVENT ONLY Sound Quality If you are listening via your computer speakers, please note that the quality of your sound will vary depending on the speed and quality of your internet connection. If the sound quality is not satisfactory, you may listen via the phone: dial 1-866-927-5568 and enter your PIN when prompted. Otherwise, please send us a chat or e-mail sound@straffordpub.com immediately so we can address the problem. If you dialed in and have any difficulties during the call, press *0 for assistance. Viewing Quality To maximize your screen, press the F11 key on your keyboard. To exit full screen, press the F11 key again.
Continuing Education Credits FOR LIVE EVENT ONLY In order for us to process your continuing education credit, you must confirm your participation in this webinar by completing and submitting the Attendance Affirmation/Evaluation after the webinar. A link to the Attendance Affirmation/Evaluation will be in the thank you email that you will receive immediately following the program. For additional information about continuing education, call us at 1-800-926-7926 ext. 35.
Program Materials FOR LIVE EVENT ONLY If you have not printed the conference materials for this program, please complete the following steps: Click on the ^ symbol next to “Conference Materials” in the middle of the left - • hand column on your screen. • Click on the tab labeled “Handouts” that appears, and there you will see a PDF of the slides for today's program. • Double click on the PDF and a separate page will open. Print the slides by clicking on the printer icon. •
Assessing Healthcare Fraud Risks, Implications of Current Enforcement & Ensuring Compliance Benjamin J. Fenton Matthew M. Curley Fenton Law Group Bass Berry & Sims PLC Los Angeles, California Nashville, Tennessee bfenton@fentonlawgroup.com mcurley@bassberry.com June 9, 2106
Healthcare Fraud Enforcements Efforts 6
Healthcare Fraud Enforcement Results Civil Fraud Recoveries FY 2011 - 2015 ($ in Billions) 6 $5.7 $4.9 5 $3.8 4 $3.6 $3.1 3 2 1 0 2011 2012 2013 2014 2015 Source: Fraud Statistics – Overview, Civil Division, U.S. DOJ 7
False Claims Act Prohibits knowingly making or causing the submission of false claims for payment to the federal government Prohibits knowingly retaining money owed to the government Provides for treble (3x) damages and per claim penalty of between $5,500 and $11,000 Allows for private parties ( qui tam relators) to bring suit on behalf of the government and participate in % of any recovery 8
Damages Theories in Civil Investigations Establishing Damages in FCA Cases • Guiding principle is “to make the government whole” for damages incurred “because of” a violation of the FCA • Measure of damages may depend on the nature of the conduct under investigation Government typically seeks money paid out because of the false claim over and above what would have been paid if the claims were truthful E.g. , healthcare provider would have received no reimbursement for claims tainted by violation of the Anti-Kickback Statute No credit for “value” received by the government for the goods or services provided to beneficiaries of government healthcare programs 9
New Qui Tam Lawsuits Number of New Qui Tam Lawsuits Filed by Year (FY 2011 - 2015) 800 750 700 650 635 600 632 550 500 2011 2012 2013 2014 2015 10 Source: Fraud Statistics – Overview, Civil Division, U.S. DOJ
FCA Relator Recoveries Relator Recoveries FY 2011-2015 ($ in Millions) 600 500 400 300 200 100 0 2011 2012 2013 2014 2015 Source: Fraud Statistics – Overview, Civil Division, U.S. DOJ 11
Stark Law Prohibits physicians and immediate family members with a direct or indirect financial interest in an entity from referring Medicare patients to that entity for “designated health services” Strict liability statute Numerous exceptions may apply Space leases Medical directorships EHR donations Violations may result in civil monetary penalties and possible exclusion May form basis of False Claims Act violation 12
Business Arrangements: Exceptions to Stark Safe Harbor for personal services and management contracts, 42 C.F.R. § 411.357(d)): • Agreement is set out in writing and signed • The agreement covers and specifies all of the services to be provided Specifies the schedule and length of time • • Not less than 1 year: If arrangement is terminated, the parties may not enter into a similar arrangement during the first of the original term. • Compensation is set out in advance and is consistent with fair market value • Cannot take into account volume or value of referrals • Hold over month-to-month (up to 6 months) following a term of at least one year is permitted assuming all provisions of the exception are satisfied. 13
Business Arrangements: Exceptions to Stark Bona Fide Employment Exception, 42 C.F.R. § 411.357(c)): • An employer may employ a bona fide employee physician (or immediate family member) if the following conditions are met: The employment is for identifiable services The amount of remuneration under the employment is consistent with fair market value Remuneration does not take into account the volume or value of any referrals by the referring physician The remuneration is provided under a commercially reasonable agreement. Payment may include productivity bonus based upon physician’s personally performed services. (i.e. RVUs ) 14
Business Arrangements: Exceptions to Stark Rental of office space or equipment, 42 C.F.R. § 411.357(a) , (b): • Payment of the use of office space made by a lessee to a lessor if there is a rental or lease agreement meeting the following conditions: Agreement is in writing, signed and specifies the premises covered. If the lease only provides access to the premises for periodic intervals, rather than on a full- time basis, the lease must specify the exact schedule and the rent for such intervals. Term of the agreement must be at least 1 year (If lease is terminated before the first year, the parties may not enter into a similar arrangement during the first year of the original term) Space rented or leased does not exceed that which is reasonable and necessary for the legitimate business purpose of the lease or rental. Space used exclusively by the lessee when being used by the lessee, except that lessee can make pro rata payments for the use of common area space Rental charges over the term are set in advance and consistent with fair market value. Rental charges over the term are set in advance and consistent with fair market value 15
Business Arrangements: Exceptions to Stark Rental of office space or equipment (cont.) • Rent is not determined in a manner that takes into account the volume or value of referrals • Not determined using a formula based on – A percentage of the revenue raised, earned, billed, collective or otherwise attributable to the services performed or business generated or Per-unit of service rental charges, to the extent that such changes reflect services provided to patients referred by the lessor to the lessee • Agreement would be commercially reasonable even if no referrals were made between the lessee and lessor • Holdover month to month rental for up to 6 months immediately following the expiration of an agreement of at least 1 year that otherwise met all the conditions above, provided the holdover period is on the same terms. 16
Business Arrangements: Exceptions to Stark Physician recruitment, 42 CFR § 411.357(e): • Remuneration by a hospital to a physician to induce the physician to relocate his or her medical practice to the “geographic area” served by the hospital in order to become a member of the hospital’s staff, if the following conditions are met: Arrangement is set out in writing and signed by both parties Not conditioned on the physician’s referral of patients to the hospital Remuneration is not determined by the volume or value of actual or anticipated referrals by the physician or other business generated between the parties Physician must be allowed to establish staff privileges at any other hospital(s) and to refer business to any other entities 17
Recommend
More recommend
