What type of charges are considered Healthcare fraud?

Providers who are alleged to have engaged in fraud and abuse are subject to sanctions under a number of Federal and State laws. Sanctions under Federal law, for example, can take the form of administrative, civil, and criminal penalties. These penalties range from monetary fines and damages to prison time and exclusion from the Federal health care programs, including Medicaid. Becoming familiar with common types of fraud, will better position providers to ensure they are not involved in such conduct. Providers will also be better equipped to identify and report others who may be engaged in fraud. Allegations can include: Medical Identity Theft, Billing for Unnecessary Services or Items, Billing for Services or Items Not Furnished, Upcoding, Kickbacks, False Claims, among others. A non exhaustive list of recent enforcement actions can be found here.

What are common federal medicare fraud charges?

Healthcare Fraud (18 USC §1347)
Aggravated Identity Theft (18 USC §1028(A)
Wire Fraud (18 USC §1343)
Money Laundering (18 USC §§1956 and 1957)
Conspiracy (18 USC §371)

Please see here for some recent criminal actions. Medicare fraud prosecutions continue to be the focus of various task forces throughout the country.

What are the five most important Federal fraud and abuse laws that apply to physicians?

1. False Claims Act (FCA) 31 U.S.C. § § 3729-3733
2. The Anti-Kickback Statute (AKS) 42 U.S.C. § 1320a-7b(b)
3. The Physician Self-Referral Law (Stark law) 42 U.S.C. § 1395nn
4. The Exclusion Authorities 42 U.S.C. § 1320a-7
5. The Civil Monetary Penalties Law (CMPL) 42 U.S.C. § 1320a-7a

What is the NPDB?

The National Practitioner Data Bank is a web-based repository of reports containing information on medical malpractice payments and certain adverse actions related to health care practitioners, providers, and suppliers. Established by Congress in 1986, it is a workforce tool that prevents practitioners from moving state to state without disclosure or discovery of previous damaging performance. If a negative report about a physician
is made to the National Practitioner Databank, for example, the physician is greatly affected.

We work with the government to try and negotiate on the language and terms that will be reported to the National Practitioner Databank. We hope to provide as much clarity on the facts surrounding the matter that led to the suspension that is being reported.

What is the OIG LEIE?

The OIG LEIE is the List of Excluded Individuals and Entities, a database maintained by the U.S. Department of Health and Human Services (HHS) Office of Inspector General. It lists healthcare professionals and organizations banned from participating in or billing federally funded healthcare programs like Medicare and Medicaid.

OIG’s LEIE provides information to the health care industry, patients and the public regarding individuals and entities currently excluded from participation in Medicare, Medicaid and all other Federal health care programs. Individuals and entities who have been reinstated are removed from the LEIE. The federal government gives a wonderful FAQ page to answer basic questions about the exclusions list.

Search the federal list here and the state of Georgia here.

Conaway & Strickler, PC has experienced healthcare attorneys ready to help with any further questions. Contact us at any time to get answers on your matter.