In 1996, the federal government passed the Health Insurance Portability and Accountability Act (HIPAA). The law was created to establish national standards to protect sensitive patient health information from being disclosed to any other party unless the patient consents. In order to implement the requirements of the standards, the HIPAA Privacy Rule was established. Entities that are subject to the Privacy Rule include healthcare providers, health plans, and healthcare clearinghouses. Violations of HIPAA can result in hefty civil fines and even criminal charges.

Examples of HIPAA Violations

There are a number of actions that could result in a violation allegation. These include:

• The medical practice is a victim of a data breach.

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According to data collected by John Hopkins patient safety professionals, medical errors are responsible for more than a quarter of a million deaths each year in this country. This major study used data collected over an eight-year period and put a spotlight on the dangers medical errors pose to patients. One of the most important factors in preventing these errors is the proper documentation by the nursing staff of the care provided to patients. Accusations of improper documentation by nurses can lead to disciplinary action or even suspension of your nursing license. The following are some of the more common documentation errors nurses are accused of making.

Illegible Writing

Although the majority of patient records are done electronically, there are still occasions where a nurse will need to handwrite patient information on a document or file. It is important that writing be done clearly and be legible for anyone who needs to read it.

Failure to Date/Time Entries

Some systems automatically enter the date and time of an entry, but if the system you are using does not offer that option, or you are handwriting the information, every entry should have the date, time, and your name.

In 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:

There 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.

There 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.