Anti-fraud guide may be useful to reporters

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism.

A just-issued 31-page guide for new physicians from HHS’ Office of the Inspector General teaches doctors how (and why) to avoid defrauding their patients and the federal government. As their public-facing antifraud campaign ramps up, the office is responding to a need for better education of medical students. It makes sense, as physicians are generally the gatekeepers for medical spending. The government doesn’t often restrict their actions on the front end, which means physicians need to know the rules before they act.

The guide is fairly engaging reading, as OIG reports go, and it may serve as a primer to reporters looking into Medicare and Medicaid fraud. It covers doctors’ relationships with payers, other providers and vendors, as well as a summary of the five primary anti-fraud statutes.

False Claims Act

Doctors shouldn’t submit claims they know are wrong, or they’ll get socked with an $11,000 fine for every little item billed falsely, in addition to repaying the cost of the item several times over. This includes upcoding, or billing for a more severe (and expensive) illness than the patient really had, or billing for an item already included in a larger overall reimbursement.roadmap

Anti-Kickback Statute

Don’t pay for patient referrals or anything else that generates business. And yes, all forms of payola are covered, not just cash.

This also extends to getting paid, whether it be by pharmaceutical companies or the college buddy who’s getting all the referrals.

Note: Doctors can waive patient copays in specific situations (they’re uninsured, can’t afford it or the doctor can’t collect), but physicians can’t do it systematically as a way to gain patients.

Physician Self-Referral Law (aka the “Stark law”)

With a couple of gigantic exceptions, doctors can’t refer patients to imaging centers that they or family members own. The rules also apply to physical therapy, prosthetics, home health services and hospital services, among other things.

Physicians can invest in health care business ventures, but they should look out for possible conflicts of interest, especially if they’re getting the sort of preferential treatment not afforded to ordinary investors.

Red flag: If the money you’re getting paid is out of proportion to the work you’re doing, then something shady is probably going on. Especially if it in any way influences the treatment your patients get.

Remember, nearly all gifts and payments from drug and device companies will be disclosed starting in 2013.

Exclusion Authorities

Doctors shouldn’t deal with folks who have already been convicted of Medicare or Medicaid fraud, patient abuse or neglect, or any related offenses. If you don’t want to get on their black list, don’t violate the other four key fraud laws.

Civil Monetary Penalties Law

CMS can seek civil monetary penalties (and black listing) if doctors violate any of the above, or provide them with false information. Physicians also need to provide adequate screening to emergency patients.

Finally, the guide ends with instructions for doctors on how to report themselves, emphasizing that doing so “allows providers to work with the Government to avoid the costs and disruptions entailed in a Government-directed investigation.”

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