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Health Care Practice Strategies – Summer 2013 - What the Feds Are Targeting

As you develop a solid compliance plan, do so with an eye toward these areas that the federal government has indicated are a high priority for enforcement:

  • Violations of the federal Stark II law (or similar state laws), which prohibits physicians from making referrals for Medicare- or Medicaid-covered designated health services to any entity in which the physician or an immediate family member has a financial interest.
  • Violations of federal and state anti-kickback laws, which prohibit giving or receiving anything of value in return for referring patients for items or services that are paid for by federally funded health care programs.
  • Billing for unnecessary services.
  • Upcoding, especially for E&M services.
  • Duplicate billing.
  • Noncompliance with the “incident to” rule, which relates to the level of supervision required for services by mid-level providers incident to a physician’s care.
  • Improper certification of medical necessity for durable medical equipment.
  • Illegitimate arrangements with billing services
  • Resubmission of unpaid claims.
  • Violations of the prohibition against reassignment of physician billing numbers
  • Use of existing physician billing numbers for new doctors waiting to receive their own numbers.
  • Failure to refund overpayments.

Source: OIG Work Plan  

Health Care Practice Strategies – Summer 2013 Issue 

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