Health Care Fraud And Abuse Compliance Manual

An immensely practical resource, Health Care Fraud and Abuse Compliance Manual provides a comprehensive overview of legislative and regulatory restrictions that affect the way health care providers conduct business and how they structure relationships among themselves. This treatise helps providers determine the boundaries of permissible conduct under the myriad statutes and regulations that relate to health care fraud and abuse at both the federal and state levels. Specific coverage includes: The statutory language in the Medicare/Medicaid civil money penalties and false claims statutes The Medicare/Medicaid antikickback statute The Stark "self-referral" law The numerous safe harbors and exceptions contained with these prohibitions And more! This authoritative resource will make you aware of your crucial obligations and options. Each chapter of the Health Care Fraud and Abuse Compliance Manual describes what the law requires, how it applies in a health care context, and what the penalties are for failure to comply. With Health Care Fraud and Abuse Compliance Manual: You'll receive coverage of all the critical laws and considerations, including: false claims and fraudulent billings, civil and criminal penalties, the antikickback statute, the safe harbor regulations, the Stark Law, and state statutes You'll get practical advice on developing a corporate compliance program that can help you stay on the right side of the law You'll learn about the structures, goals, and procedures of agencies that investigate health care fraud You'll get an in-depth understanding of what goes into a fraud and abuse investigation - and how you can respond to an investigation to best defend your organization And much, much more! Health Care Fraud and Abuse Compliance Manual has been updated to include: Updated nationwide health care fraud and abuse enforcement statistics OIG Work Plan for FY 12 (Medicaid projects) Enforcement actions involving billing for services of unlicensed personnel Enforcement actions involving billing without proper documentation Enforcement actions involving illegal inducements to beneficiaries Hospital liability for submission of false cost reports Cases involving maximum hospital liability for EMTALA violations Criminal false claims liability for unsolicited telemarketing by a DME supplier Managed care provider liability for cherry-picking, retaining overpayments, and other practices Hospice liability for providing services to ineligible patients Pharmaceutical manufacturer liability for pricing-related false claims violations Enforcement actions involving federal research grant fraud Criminal kickback liability for sham consulting arrangements Self-referral liability for office lease agreements and independent contractor relationships inconsistent with fair market value or not memorialized in writing Updated Medicaid Fraud Control Unit performance standards (MFCU) False claims laws of Massachusetts, Montana, and Nevada OIG evaluation of Massachusetts, Montana, and Nevada false claims laws

A guide for physicians covering the legal aspects of health insurance and offers ways to design an effective billing, coding, and accounts receivable process.

The Health Care Compliance Professional's Manual is one of the most vital, long-standing, and best known resources in the world of health care compliance. It has all the tools you and your compliance team need to plan and execute a customized compliance program. This new edition is filled with industry best practices, sample forms, policies, procedures, and much more to save you time and comply with federal standards. The Health Care Compliance Professional's Manual will help you to: Use OIG publications and Federal Sentencing Guidelines to plan and execute a customized compliance strategy that meets tough federal standards and minimizes enforcement risks Oversee physician compensation and referrals Perform risk assessments using matrixes with step-by-step instructions to pinpoint areas that pose compliance and operational risks Draft compliance policies that form the foundation for a strong compliance program Build a strong infrastructure reinforced by industry best practices Create an effective education and training program that instills in employees the importance of legal compliance Implement a privacy and security plan that ensures patient information is protected Stay up-to-date on the latest legal and state and federal regulatory requirements affecting your facility, in areas such as HIPAA, EMTALA, fraud and abuse, reimbursement, privacy, security, patient safety, and clinical research Study for CCB(R) Certification in Healthcare Compliance (CHC) Packed with tools to make your job easier and more efficient, The Health Care Compliance Professional's Manual will provide: Practical coverage of federal and state laws governing your facility Insight into helpful federal standards on effective compliance programs Step-by-step guidance on implementing a sound compliance program Examples of common risk areas and how to handle them Time savings and peace of mind from sample policies, checklists and forms from members of the American Health Law Association (AHLA) The Health Care Compliance Professional's Manual will help you protect your company if violations do occur: Learn how to apply auditing, monitoring, and self-assessment techniques for conducting internal investigations Discover how to successfully follow the OIG's voluntary disclosure program to resolve overpayment problems and avoid exclusion from Medicare Find out how to enter into a corporate integrity agreement to settle with the federal government and mitigate FCA-related penalties Document your compliance efforts so you leave a protective paper trail that shields you from liability And much more Previous Edition: Health Care Compliance Professional's Manual, Second Edition ISBN: 9781543813265 SKU: 10071961-7777

Useful for Doctors, Nurses, Dentists, Therapists, Podiatrists, Osteopaths, Physicians Assistants, Practice Administrators, Compliance Officers, and all Allied Health Professionals, for Medicare, Medicaid, and Private Insurance.

The fight against fraud and abuse in healthcare programs, and the pharmaceutical and medical devices industry in particular, continues to grow. Since 1996 the federal government has strengthened its efforts to detect and prevent fraud and abuse in healthcare, and has recovered $18 billion since 1997. These enforcement activities make a compliance program essential to protecting a company from running afoul of the myriad laws and regulations that have been enacted to combat fraud and waste. Pharmaceutical and Medical Device Compliance Manual includes guidance to help companies do that.Coverage includes:In-depth coverage of the federal and state enforcement agenciesFederal Anti-Kickback Statute and False Claims Act detailsDistinction between manufacturers' lawful dissemination of scientific information and unlawful promotion of off-label useDiscussion of the Foreign Corrupt Practices Act and its extra-territorial reachCoverage and reimbursement of prescription drugs and medical devicesPrescription drug price regulationsThe Manual includes guidance on building an effective compliance program and will be a great tool for health and life sciences attorneys, compliance officers, and others in the pharmaceutical and medical devices industry.EDITORSKathleen M. Boozang, J.D., LL.M., Professor of Law, SETON HALL LAW, Center for Health & Pharmaceutical Law & Policy, Newark, NJSimone Handler-Hutchinson, J.D., Executive Director, SETON HALL LAW, Center for Health & Pharmaceutical Law & Policy, Newark, NJCONTRIBUTING AUTHORSBret A. Campbell, Esquire; Cadwalader, Wickersham & Taft LLP, Washington, DC; Sujata Dayal, Esquire; Biomet, Inc., Warsaw, IN; Michael Andre Donnella, Esquire; Wyeth, Madison, NJ; Katie Rose Fink, Esquire; U.S. Dept. of Health & Human Services, Office of Inspector General, Washington, DC; Brett R. Friedman, Esquire; Ropes & Gray, LLP, New York. NY; Gary F. Giampetruzzi, Esquire; Pfizer, Inc., New York, NY; Christopher R. Hall, Esquire; Saul Ewing, LLP, Philadelphia, PA; Patrick M. Hromisin, Esquire; Saul Ewing, LLP, Philadelphia, PA; Elizabeth H. Kim, Esquire; Porzio Life Sciences, LLC, Morristown, NJ; Daniel A. Kracov, Esquire; Arnold & Porter, LLP; Washington, DC; Bruce A. Levy, Esquire; Gibbons, PC., Newark, NJ; Ann E. Lewis, Esquire; Ropes & Gray, LLP, New York. NY; Benjamin S. Martin, Esquire; Epstein Becker & Green, PC, Washington, DC; Joseph W. Metro, Esquire; Reed Smith, LLP, Washington, DC; Lewis Morris, Esquire; U.S. Dept. of Health & Human Services, Office of Inspector General, Washington, DC; Kiaema R. Reid; Porzio Life Sciences, LLC, Morristown, NJ; Linda Pissott Reig, Esquire; Buchanan Ingersoll & Rooney, PC, Newark, NJ; Margaret Renner, Esquire; FDA (formerly Arnold & Porter), Silver Spring, MD; Mary Riordan, Esquire; U.S. Dept. of Health & Human Services, Office of Inspector General, Washington, DC; Lynn Shapiro Snyder, Esquire; Epstein Becker & Green, PC, Washington, DC; Brian Tretick; Athena Privacy, LLC, Washington, DC; Robert E. Wanerman, Esquire; Epstein Becker & Green, PC, Washington, DC; and Mara E. Zazzali-Hogan, Esquire, Gibbons, PC., Newark, NJ

The Health Care Compliance Professional's Manual gives you all the tools you need to plan and execute a customized compliance program that meets federal standards. It walks you through the entire process, start to finish, showing you how to draft compliance policies, build a strong compliance infrastructure in your organization, document your efforts, apply self-assessment techniques, create an effective education program, pinpoint areas of risk, conduct internal probes and much more. The Health Care Compliance Professional's Manual is used by the Health Care Compliance Association (HCCA) as the basic text for its Compliance Academy - the program that prepares compliance professionals for the CHC (Certificate in Healthcare Compliance) certification exam. The Health Care Compliance Professional's Manual will help you to: Use OIG publications and Federal Sentencing Guidelines to help plan and execute a customized compliance strategy that meets tough federal standards Perform risk assessment to pinpoint areas within your company that pose compliance and operational risks Draft compliance policies that form the foundation for a strong compliance program Build a strong infrastructure for compliance to work, including hiring the right personnel Create an effective education and training program that instills in employees the value of legal compliance Conduct internal probes that uncover legal violations before the federal government does - and mitigate possible penalties Stay up-to-date on all the latest legal and regulatory requirements affecting your facility, including HIPAA, EMTALA, fraud and abuse reimbursement, privacy, security, patient safety and much more! Packed with tools to make your job easier, The Health Care Compliance Professional's Manual will provide: Practical coverage of federal and state laws governing your facility Document efforts and apply self assessment techniques Insight into helpful federal standards on effective compliance programs Step-by-step guidance on implementing a sound compliance program Time-saving sample compliance policies, forms, checklists, and chart The Health Care Compliance Professional's Manual will protect your company if violations do occur: Learn how to apply auditing, monitoring, and self-assessment techniques Discover how to successfully follow the OIG's voluntary disclosure program to resolve overpayment problems and avoid exclusion from Medicare Find out how to enter into a corporate integrity agreement to settle with the federal government and mitigate FCA-related penalties Document your compliance efforts so you leave a protective paper trail that shields you from liability And much more

Authored by experts with years of health care compliance experience, this new edition integrates changes in regulation, trends in enforcement, and the reasoning of the courts to help you navigate emerging and unsettled areas of compliance risk, such as self-disclosure obligations, risks associated with opioid use, and the impact of statistical sampling.Highlights of this edition include:All new glossary of health care compliance terms, including key statutes, acronyms, governing agencies, and moreExpanded civil monetary penalty and exclusion authorities under 2017 final rulesDiscussion of core elements of compliance programs for Medicare Advantage Plans and Part D Plans as established by federal regulationsExpanded whistleblower protections under federal and state law, false claims based on lack of medical necessity, materiality after Escobar, and recent enforcement activityExpanded discussion of determinations of medical necessity, CMS review of medical necessity terminations, consequences, and appeals processesRecent health information privacy and security developments, including new guidance, risks associated with innovative technologies, and trends in Health Insurance Portability and Accountability Act (HIPAA) enforcement activityNew chapters:Chapter 1, Glossary of Key TermsChapter 10, The Relationship between Enforcement and ComplianceChapter 17, Health Care Civil Rights and Nondiscrimination Under Section 1557 of the Affordable Care ActChapter 19, Behavioral Health