Health Care Fraud and Abuse Regulatory Framework and Compliance

Fraud, Waste and Abuse issues are central to all heath care providers who receive any federal funding.  We provide counseling and advisory services for clients working to ensure compliance with fraud and abuse regulations and representation for providers who are under investigation.

Most fraud and abuse matters relate primarily to the Stark law, the Anti-Kickback Statute, and the False Claims Act, but there are always implications for the Civil Money Penalties law and the CMS Exclusion Authorities.  Most significantly, there are criminal as well as civil penalties for violations of many fraud and abuse laws, and providers need counsel to avoid admitting conduct which could be used to advance criminal charges.

Regulatory Analysis of Proposed Ventures or Transactions

Providers most often need assistance with regulatory analysis for a proposed business relationship, and negotiation of civil money penalties or federal program exclusion actions.    (is this what you want to say? I’m not sure how the preceding items relate to each other) Whether leasing office space, contracting with a referring physician, making relocation or other recruiting payments to support a new hire, or entering a relationship with a potential referral source or recipient, there are complex regulations governing the relationship.  We advise providers on what they need to do to meet the appropriate legal requirements.

Responding to Federal Billing Audits

In addition to Medicare or Medicaid audits or repayment demands, audits may arise from the Comprehensive Error Rate Testing (CERT) program, the Zone Program Integrity Contractor (ZPIC) program, Payment Error Rate Measurement (PERM) audits, or numerous other fraud and abuse monitoring initiatives.  Responding to these audits, and appealing unfavorable decisions, requires experienced counsel.  We help clients respond to audits and can assist in representing them in inquiries.

Negotiating Federal Enforcement Sanctions

Negotiation of civil money penalties or federal program exclusion actions requires knowledge of complex regulations as well as experience working with the administrative agencies.   Providers should not attempt to manage pending sanctions without experienced counsel.  We assist clients in seeking the optimal outcomes for these matters.

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