Physicians Breaking the Law or Meeting Compliance Rules

Compliance Rules

The majority of physicians try to work ethically, deliver top-quality medical care to patients, and submit correct claims for imbursement. A strong conviction is at the center of the physician-patient relationship. In addition the Federal Government has enormous trust in physicians. Medicare and other Federal health care plans depend on on physicians’ medical judgment to treat patients with the right services. The Federal Government expects physicians to submit correct claims when requesting payment for Medicare-covered health care items and services.

A few incidences of dishonest health care professionals who abuse Federal health care programs for unlawful private advances has made the need for laws that contest fraud and abuse and safeguard suitable quality medical care. During their careers, physicians commonly come across the following three types of business relationships that may prompt fraud and abuse concerns:

  1. Relationships with payers
  2. Relationships with fellow physicians and other providers
  3. Relationships with vendors

The following Federal fraud and abuse laws that apply to physicians are:

  • False Claims Act (FCA)
  • Anti-Kickback Statute (AKS)
  • Physician Self-Referral Law (Stark Law)
  • Social Security Act
  • United States Criminal Code

Breaking any these laws may effect nonpayment of claims, Civil Monetary Penalties (CMPs), barring from all Federal health care programs (including Medicare), and criminal and civil liability.

The Federal False Claims Act (FCA)

The FCA protects the Federal Government from being overcharged or sold substandard goods or services. The FCA imposes civil liability on any person who knowingly submits, or causes the submission of, a false or fraudulent claim to the Federal Government. The terms “knowing” and “knowingly” mean a person has actual knowledge of the information or acts in deliberate ignorance or reckless disregard of the truth or falsity of the information related to the claim. No proof of specific intent to defraud is required to violate the civil FCA.

For more on physician payment monitoring program to avoid stark violations, join Marcie R. Swenson, RN, JD, LLM, CHC, in this webinar on Bona Fide Physician Contracting & Payment to learn why a physician payment monitoring program is the only way to guarantee that payments are being made strictly according to contract terms, and how it helps in avoiding Stark violations.

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