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Healthcare Fraud

What is a Kickback Scheme?

By Susan Schneider Thomas Quite simply, a kickback is an inducement – offering or giving something of value in exchange for getting business referrals. Although that type of behavior can be perfectly legal in some segments of the commercial world, it is not permitted when the business that is being referred is paid for [...]

What are Medically Unnecessary Services?

By Susan Schneider Thomas Medical necessity has implications for good, safe patient care and for reimbursement or payment decisions. Although an unnecessary treatment is not always dangerous, it could be used in place of a more appropriate treatment. It could also have side effects or risks that are not justified when the treatment is [...]

Common Types of Pharmaceutical Fraud

By Daniel Miller Pharmacy fraud can take many forms, some of which can be very costly to taxpayers when the pharmaceuticals involved are paid for by government-funded health programs like Medicare or Medicaid. Some of the most common types of pharmacy fraud include: auto-refilling fraud, off-label marketing of drugs, average manufacturer price/best price fraud, [...]

What are Anti-Kickback Safe Harbors?

By Daniel Miller The federal Anti-Kickback Statute (“AKS”) imposes penalties on anyone who, knowingly or willfully, offers, pays, solicits, or accepts remuneration in exchange for referrals or payments for goods or services reimbursable under a federal health care program.[i] Congress enacted the AKS in 1972, and its primary purpose is “to protect patients and [...]

Upcoding Medical Billing

By Jonathan DeSantis When a provider treats a Medicare patient, the provider must tell Medicare what services were provided so that Medicare can reimburse the doctor the correct amount. Certain services have higher reimbursement amounts than others –a more serious condition will generally be more expensive for the provider to treat and thus, the [...]

Anti-Kickback Statute Safe Harbor: Personal Services and Management Contracts

By Russell Paul The Anti-Kickback Statute, 42 U.S.C. § 1320a-7b(b) (“AKS”), prohibits anyone from knowingly and willfully offering, paying, soliciting, or receiving remuneration in order to induce reimbursable business under federal or state healthcare programs. The Department of Health and Human Services has enacted safe harbor regulations that define practices that are not subject to [...]

Home Healthcare Fraud and the False Claims Act

By William Ellerbe Home healthcare is a vital service that many Americans rely on. Unfortunately, because of some aspects of the delivery system for home healthcare, and because the patients who receive home healthcare services may be the targets of unscrupulous providers, there is the potential for fraud in home healthcare. Examples of home [...]

Use of Hospital-Employed Non-Physician Providers by Private Physicians May Violate the Anti-Kickback Statute

By Shauna Itri The Anti-Kickback Statute (“AKS”) prohibits any person or entity from offering, making, soliciting, or accepting remuneration, in cash or in kind, directly or indirectly, to induce or reward any person for purchasing, ordering, or recommending or arranging for the purchasing or ordering of federally-funded medical goods or services. Whoever knowingly and [...]

What is Hospice Fraud?

By Russell Paul Medicare Part A covers hospice care when a patient is certified as “terminally ill.” See e.g. 42 C.F.R. §§ 418.20, 418.22. “Terminally ill” means that a patient’s medical prognosis is for a life expectancy of six months or less due to the patient’s particular disease if it runs its normal course. See [...]

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