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illinois license defense lawyerIn order to protect patients who are covered under federal health programs, such as Medicaid and Medicare, the federal government has put in place certain laws that medical providers are required to adhere to. The Department of Health & Human Services Office of Inspector General (OIG), the Centers for Medicare & Medicaid Services (CMS), and several other federal agencies are in charge of making sure these laws are followed, and to investigate and prosecute those who do not. We have discussed two of them – the Physician Self-Referral Law (Stark Law)  and the Federal Anti-Kickback Statute (AKS) – in prior posts. In this third and final post about these laws, we will discuss the False Claims Act.

The False Claims Act

Violations of the Stark Law result in civil penalties, while violations of the AKS result in criminal penalties. The False Claims Act (FCA) has both criminal and civil penalties, depending on what the government thinks the intent of the individual being charged was.

Some examples of false claims include:

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b2ap3_thumbnail_shutterstock_1692451894.jpgThere are several federal laws that have been put in place in order to protect patients by ensuring that there are no financial incentives or other conflicts of interest regarding referrals by healthcare providers. In our last post, we discussed the seriousness any accusations of violating the Physician Self-Referral Law (Stark Law) can have on a physician’s career. In this post, we will address the Federal Anti-Kickback Statute.

Federal Anti-Kickback Statute

Unlike the Stark Law, in which any violations are met with civil penalties, the Anti-Kickback Statute (AKS) is a criminal law, meaning that if a provider is found guilty of violating the statute, they now have a criminal record and could even face jail time depending on the circumstances of their case. Any criminal charges are classified as a felony.  

Under the AKS, it is a criminal offense to either exchange or offer to exchange something of value in order to persuade business referrals that would be reimbursed by any federal health care program, such as healthcare services and prescription medications.

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b2ap3_thumbnail_shutterstock_1100432048.jpgThere are many federal and state laws that physicians are required to abide by, including laws that address fraud and abuse. According to the Office of Inspector General, U.S. Department of Health and Human Services (OIG), the most serious of these laws include the Physician Self-Referral Law (Stark Law), the Anti-Kickback Statute (AKS), and the False Claims Act (FCA). Violations of these laws can result in severer penalties, including exclusion from federal health care programs, civil fines, loss of medical license, and even criminal penalties. In our next few posts, we will discuss each of these laws and how they may affect your practice. In this post, we will look at the Stark Law.

The Physician Self-Referral Law

The Physician Self-Referral Law, referred to as the Stark Law, bans doctors from referring patients to other medical providers for services that will be paid by Medicare, Medicaid, or other programs if the referring doctor or a member of their immediate family has any type of financial relationship with the medical provider they are referring. Basically, a doctor cannot refer a patient in exchange for receipt from that provider of anything of value. They also cannot present claims to Medicare or other healthcare program for referred services.

The Stark Law is meant to protect patients from procedures – and medical expenses – that are unnecessary. It also applies to all medical facilities, whether a small private practice or a large health care system. There are some exceptions to the Stark law, however, those exceptions are very limited.

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illinois license defense lawyerIn the healthcare industry, pharmacy benefit managers (PBMs) serve a pivotal role. In fact, a pharmacy would be unable to operate without having a contract with a PBM. The PBM serves as an intermediary between the pharmacy and the insurance company, negotiating rates and processing the majority of all prescriptions.

Under these contracts, the PBM also has the right to conduct an audit of the pharmacy to make sure that all terms of the contract and proper guidelines are being met. Any discrepancies found during the audit could result in not only the pharmacy being required to pay back funds they have received, but could also result in the PBM contract being terminated. One product PBMs have been laser focused on recently is the number of pharmacies purchasing diabetic testing strips from unauthorized sources.

Black Market Diabetic Testing Strips

There are currently more than 30 million patients diagnosed with diabetes in this country. Patients who have the condition are required to test their glucose levels each day. One of the most common ways to test is by using diabetic test strips. It is so common revenues from these test strips surpasses $8 billion a year.

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 b2ap3_thumbnail_shutterstock_1297756882.jpgOver the past few decades, the experience of labor and delivery for women has undergone dramatic changes. The process used to be a very clinical one, ending in a birthing experience that involved drugging the mother from the moment she arrived at the hospital and keeping the newborns in the nursery instead of with their mothers for the majority of their extended hospital stays.

The attitude about the birthing process has all changed to a much more family-intimate experience. This has also led to many women choosing to entrust their care to midwives instead of obstetricians. Some women even decide to have their babies born at home, whether by choice or because of the astronomical expense of a hospital delivery.

However, until recently, only those who were certified as nurse-midwives could provide Illinois women with this type of care, but a new law recently signed by the governor will create a new license process for midwives that does not require a nursing degree.

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