2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Fraud, Waste, and Abuse• State laws pertaining to civil or criminalpenalties for false claims and statements• Detecting and preventing fraud, waste,and abuse• Rights of employees to be protected aswhistleblowersAnti-Kickback LawsThe anti-kickback laws prohibit anyone fromknowingly and deliberately offering, giving, orreceiving remuneration in exchange for referrals ofhealth care goods or services that are paid for inwhole or in part by Medicare or Medicaid.Penalties include:Criminal: jail time, $25,000 fine, mandatoryexclusion from participation in most federalhealth care programs including Medicare andMedicaidCivil: penalties and fines, permissive exclusionAnti-Kickback Safe HarborsCongress added to the law provisions thatdesignate certain provider activities as “safeharbors,” which are specified as not constitutingviolations of the statute.Safe harbors allow certain activities to take placethat may appear on the surface to be violations ofthe law, but those activities are very restricted andmust take place only when all of the safe harborconditions are met. There are many complicatedsafe harbor exceptions, such asPersonal services contractsPayment based on fair market value ofservices, not value of referralSale of practiceProper discounts and rebatesExamples of these exceptions includeDrug “switching” programs – if structuredincorrectlyDrug rebate programs – if structuredincorrectlyPharmacy paid to “steer” patients to specificPart D planSelf-Referral LawsThe physician self-referral law, commonly referredto as the “Stark Law,” prohibits a physician fromreferring patients for certain designated healthservices to an entity in which the physician (or animmediate family member of that physician) has anownership interest or with which the physician (oran immediate family member of that physician) hasany compensation or other relationship thatinvolves remuneration or other benefit unlesscertain prescriptive requirements are met.If those requirements are not met, the entity maynot bill for any designated health service furnishedpursuant to the prohibited referral. Examples ofdesignated health services are inpatient andoutpatient hospital services, outpatient prescriptiondrugs, home health services, durable medicalequipment and supplies, and clinical laboratoryservices. The assumption underlying the statute isthat allowing such referrals would lead tounnecessary tests and increase costs. The statute15-102014 Practitioner and Provider Manual - Ver. 3