Stand Alone Project Compliance Sample

Stand Alone Project Compliance
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Stand Alone project Compliance
Introduction
Compliance is a critical component of healthcare in the U.S. Healthcare compliance compels healthcare organizations, institutions, and providers to develop effective and practical processes, regulations, standards, and procedures to define expected practice organizational staff education and training and monitor endearment the processes policies and procedures. Physicians are faced with extra responsibilities of coping with and enforcing healthcare compliance requirements in their workplace. More than ever, the previous and emerging healthcare regulations, laws and policies, culminates in the need for increased compliance. Physicians need to be skillful and knowledgeable about health compliance. This paper reflects an overall plan to build knowledge, experience, processes, and standards in the physicians ‘work points, including their offices, clinics, and hospitals. Physicians need to develop compliance programs that ensure the adoption of appropriate compliance and adherence to health regulations. Why should physicians have a compliance program? What is the scope of compliance? What are the benefits associated with adopting compliance programs in physicians' offices? As a newly hired compliance manager, I am responsible for ensuring adequate compliance to standards, policies, and procures encapsulated in health regulations and laws in physician healthcare outfits. I am tasked with reviewing procedures, standards, and processes within our network of physicians, analyzing compliance levels, and providing compliance feedback to physicians.
Healthcare is one of the highly regulated fields in the U.S. Thus, healthcare compliance a crucial and growing field within the industry that cannot get ignored by physicians, hospitals, and other healthcare providers. Healthcare compliance professionals are required to assist clinical facilities and organizations in addressing the ever-increasing government regulations. Such regulations often focus on privacy rights and standards regarding the use of patient data, promoting quality patient care, deterring fraud, and protecting healthcare staff.
Part A: False Claims Act Violations
The False Claim Act (FCA) is a critical act crafted to curb or stem fraudulent medical claims. The federal government curtails fraudulent obtained medical payments using FCA as a critical tool (Krause, 2017). The FCA is the government's primary tool for fighting health care fraud, kickbacks, and conspiracies. FCA provides that any part knowingly submits false claims can be held liable to threefold the government's damages plus monetary penalties. However, there are various risk areas in which physician groups and healthcare providers or facilities are exposed, leading to violation of FCA.
First, submission of claims for services not rendered is one of the core areas that physicians and healthcare providers are at risk of violating FCA. Therefore, billing for services not rendered is considered an infringement of FCA, leading to lawsuits and penalties. Second, billing for one service more than once is considered a violation of FCA. Third, performing unnecessary healthcare interventions for financial interest and incentives goes against the principles of FCA. Fourth, taking or giving a kickback, rewards, or remuneration for a referral violates FCA directives. Fifth, physicians and healthcare providers are exposed to the risk of violating FCA when they do procedures that cost less but falsely claim costlier procedures or treatment interventions. Besides, whistleblowers of fraudulent medical claims are protected under FCA. Thus, healthcare providers who punished whistleblowers, including their employees, for whistleblowing are considered to have contravened the FCA, thereby, can be held liable for violating FCA. These FCA risk areas should be critical aspects that compliance managers should be abreast with and take measures to brief physicians and other healthcare providers.
Thus, FCA has been critical legislation in advancing the fight against medical fraud. For instance, FCA's localized fraud enforcement unit recovered $2.5 billion in fraudulent healthcare expenditure in 2016 (Nguyen & Perez,2020). According to Nguyen & Perez (2020), the FCA is increasingly using private persons or citizens to pursue civil fraud proceedings on behalf of FCA, the state, or qui tam. The scope of compliance extends to fraud and abuse. Accordingly, various statutes, laws, statutes, and various units exist to combat fraud and inefficiencies. Physicians and compliance professionals must understand these laws because violations can result in criminal charges and fines. In addition, physicians may lose their medical licenses. Medicaid Fraud Control Units (MFCU) investigate and prosecute Medicaid provider fraud. Fraudulent claiming within federal healthcare programs can be investigated and prosecuted under the False Claims Act. Each state has its MFCU. Healthcare compliance can work with the MFCU to ensure compliance through auditing and monitoring for fraudulent activities. The Fraud Claim Act, which is federal law, is broadly applied legislation. The False Claim Act makes it a crime for any party to knowingly make a false record or file a false claim in federally funded medical programs.
The False Claims Act permits private individuals or parties to file a lawsuit against parties, physicians, or healthcare business units participating in fraud and abuse in federally funded healthcare programs. Even though the federal government can file its False Claims Act lawsuit, whistleblowers have successfully prosecuted fraudulent cases. Violators of the False Claims Act are compelled to pay up to threefold the amount the federal government lost. In addition, infringements of the False Claims Act can lead to collateral outcomes on dependents, including being excluded from future federal and state federally funded healthcare programs.
Part B: Stark Law Violation
Stark Law is critical health regulation for healthcare practice. For my employer, Stark law is relevant for healthcare providers, especially physicians. The Stark law is considered legislation geared towards battling fraud and abuse involving referrals tied to financial interests. The financial relationship is quite broad, including ownership of the business, rewards for referrals, and other vested interests. Unlike the federal Anti-Kickback Statute, Stark law is not criminal law. OIG can pursue civil action against parties who violate Stark Law. The Stark Law is a strict liability statute. Thus, non-compliance to Stark Law cannot be proven by the physician's intent. Therefore, physicians who make referrals inclined towards specific service or product units accidentally or knowingly are exposed to civil penalties. Severe civil penalties such as debarment and exclusion from participating in federally funded healthcare programs can be imposed on the violators of Stark Law. Stark Law penalties are not severe as the Anti-Kickback Statutes. However, they can cost physician's substantial damage. Civil penalties for the Stark Law infringements include overpayment refund obligation, False Claims Act liability, civil monetary penalties, and federal healthcare program exclusion. However, there is are a particular exception in which physicians can refer patients under federal healthcare programs such as Medicaid and Medicare without violating Stark law. For instance, physicians can make referrals for in-office-ancillary services, especially in group medical practice and Fair Market Compensation Exception (LaPenna, 2020).
There are many instances in which Stark Law has been violated. This section will demonstrate three cases under which Stark Law has been violated. First, there is a case of Adventist Health System, which was made to pay the U.S $115 million to settle allegations of violating the False Claims Act by practicing improper compensation arrangements with referring physicians and miscoding claims U. S Department of Justice (2015). This settlement resulted from unlawful financial arrangements between health care providers and their referral sources. The financial arrangement in the Adventist Health System case raises concerns regarding physician independence and objectivity. Patients should access healthcare services based on their actual health needs rather than the financial interests of their physician. The physicians at Adventist Health System received bonuses based on physicians’ referrals to Adventist hospitals. Federal law prohibits financial relationships in healthcare organizations or units with doctors who refer patients to them U. S Department of Justice (2013). Adventist Health System case reflects a practice that violates Stark Law.
The second case involved Infirmary Health System. In this case, Infirmary Health System Inc., IMC-Diagnostic and Medical Clinic, and Diagnostic Physicians Group P.C. were charged with contravening the Anti-Kickback Statute and the Stark Law. The violators fraudulently billed the government over $500 million due to the illegal kickback scheme (U.S Department of Justice,2013). In this case, IMC-Diagnostic and Medical Clinic improperly paid Diagnostic Physicians Group compensation, including portions of the money from the federal health program plan for tests and procedures the doctors referred to the clinic. The claims presented violated both violated the Stark Law and Anti-Kickback Statute.
Third, in Tuomey Healthcare System, it was found that the provider violated Stark law. It culminates in infringement of the Stark Law when healthcare providers contract with outside physicians to do surgeries exclusively in its facilities and reward them with bonuses for performance (Wang, 2019). Tuomey Healthcare System in Sumter, S.C., infringed the FCA by submitting bills to Medicare and lucratively paying physicians so that such doctors may not refer well-paying patients to other facilities if physicians were not well compensated (Wang, 2019). The referral associated with financial interests or inhibiting referral due to vested interests culminates in violation of Stark Law.
As a compliance manager, it is critical to be abreast with Stark Law and promote practice and procedures in line with Stark Law. It is vital to inform review the hospital practices, perceptions, and procedures on referral activities. Physicians and other healthcare staff should be informed about the relevance of complying with Stark Law. The whole referral system should be reviewed. In addition, the compensation, reward, and bonus system for physicians and other healthcare providers should be reviewed to ensure that it is proper and cannot infringe the core tenets of Stark Law. Compensation or bonus system that influences referral system culminates in improper compensation, thereby violating the principles of Stark Law.
The Physician Self-Referral Law, Stark Law, and Anti-kickback Statute prohibit physicians from referring patients covered by Medicare, Medicaid to treatment or service entities such as physician offices, care facilities, pharmaceutical drugs that the referring physician has a financial relationship with. Federal physician self-referral prohibition (42 USC 1395nn.), often called the Stark law, comprises physician self-referral regulations (Kapoor,2015). Its statutes are espoused in Centers for Medicare & Medicaid Services (CMS) fraud and abuse laws. Stark law limits the financial and business relationships or affiliations with physicians where such physicians may have vested financial and business interests. The federal Anti-Kickback Statute is a criminal statute prohibiting the exchange or offers to exchange any value that may induce or reward business referral. Kickbacks such as receiving financial rewards or remunerations for referrals, free or discounted services excessive compensation are prohibited. The Centers for Medicare and Medicaid Services (CMS) argues that kickbacks lead to overutilization of healthcare s...