The Exclusion Statute

Posted on Jul 25, 2019 in Medicare Compliance, Medicare Fraud

The Exclusion Statute

Your Anesthesia Compliance Tip for today is on the

Exclusion Statute:

Through the Exclusion Statute, the Office of Inspector General has the authority to exclude individuals and entities from Federally funded healthcare programs. In addition, it also maintains a list of all presently excluded entities and individuals. This list is commonly known as the List of Excluded Individuals/Entities (LEIE). Most importantly, all organizations who hire an individual or entity that your foresee will participate in a government program must review this list.

Initially we must focus on Mandatory exclusions:

First of these are the exclusions by which the OIG is required by law to exclude from participation in all Federal health care programs individuals convicted of the following types of criminal offenses:

  1. Initially, Medicare or Medicaid fraud, or any offenses related to the delivery of services under Medicare, Medicaid, or State programs
  2. Secondly, patient abuse or neglect
  3. Next, felony convictions for health care-related fraud, theft, or other financial misconduct
  4. Finally, felony convictions relating to unlawful manufacture, distribution prescription, or dispensing of controlled substances

 Secondly there are Permissive exclusions:

These are exclusions in which the OIG has discretion to exclude individuals and entities on a number of grounds,

  1. First, are misdemeanor convictions related to health care fraud other than Medicare or a State health program
  2. Fraud in a program funded by any Federal, State or local government agency
  3. Misdemeanor convictions relating to the unlawful manufacture, distribution, prescription, or dispensing of controlled substances
  4. Suspension, revocation, or surrender of a license to provide health care for reasons bearing on professional competence, professional performance, or financial integrity
  5. Provision of unnecessary or substandard services
  6. Submission of false or fraudulent claims to a Federal health care program
  7. Engaging in unlawful kickback arrangements
  8. Finally, defaulting on health education loan or scholarship obligations; and controlling a sanctioned entity as an owner, officer, or managing employee

Most important, to avoid Civil Monetary Penalty liability, health care entities need to routinely check the (LEIE) List of Excluded Individuals and Entities to ensure that new hires and current employees are not on the excluded list. Above all it is perilous to ignore the Exclusion Statute. For any questions feel free to contact us.

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The Anti-Kickback Statute

Posted on Jun 24, 2019 in Billing, Medicare Compliance, Medicare Fraud

The Anti-Kickback Statute

A Criminal Law

The Anti-Kickback Statute is a criminal law that prohibits the knowing and willful payment or “remuneration” to induce or reward patient referrals.  It also applies to  the generation of business involving any item or service payable by the Federal health care programs. Remuneration includes anything of value and can take many forms besides cash, such as free rent, expensive hotel stays and meals, and excessive compensation for medical directorships or consultancies. Learn more.


Criminal penalties and administrative sanctions for violating the Anti-Kickback Statute include fines, jail terms, and exclusion from participation in the Federal health care programs. Under this law, physicians who pay or accept kickbacksalso face penalties of up to $50,000 per kickback plus three times the amount of the remuneration.

Target for Kickbacks

As a physician, you are an attractive target for kickback schemes because you can be a source of referrals for fellow physicians or other health care providers and suppliers. You decide what drugs your patients use, which specialists they see, and what health care services and supplies they receive. Many companies will attempt to take advantage of this relationship. They will attempt to pay you for the referrals.

Moreover, just as it is illegal for you to take money from providers and suppliers in return for the referral of your Medicare and Medicaid patients, it is illegal for you to pay others to refer their Medicare and Medicaid patients to you.

In addition, Medicare and Medicaid programs require patients to pay copays for services and you are required to collect them. Waiving these copays could implicate the Anti-Kickback Statute. Of course it is OK to waive if the patient cannot afford or if you have made efforts to collect.

Contact us for more information on these important topics and anesthesia compliance training for you and your company.

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False Claims Act and Anesthesia

Posted on Jun 5, 2019 in Billing, Compliance, Medicare Compliance

False Claims Act and Anesthesia

An Important Law

The Federal False Claims Act and anesthesia is a topic worth considering. Of note, there are many federal laws in place that govern Medicare fraud and abuse. One of the most important laws that addresses fraud is the Federal False Claims Act.    Most importantly, it allows private citizens to bring civil actions on behalf of the United States.

The False Claims Act protects the Federal Government from overcharging or selling substandard goods or services. Consequently it imposes civil liability on any person who knowingly submits, or causes the submission of, a false or fraudulent claim to the Federal Government. Of interest, this is a law that dates back to the Civil War era.

Knowledge of Wrongdoing

The terms “knowing” and “knowingly” mean a person has actual knowledge of the information or acts in deliberate ignorance or reckless disregard of the truth or falsity of the information related to the claim. Furthermore, to violate the False Claims Act does not require proof of specific intent to defraud.

Qui Tam Complaint

The qui tam provision allows a person to file a qui tam action. Initially the government seals the qui tam complaint 60 days. Secondly, during this time the government will investigate the allegations and decide if it is proceeding with the action. Eventually if convinced by the case the government will prosecute. Finally, the individual who initially brought the case may receive between 15 and 25 percent of the amount recovered by the government.

Lack of Compliance Plan

Of importance is that the lack of a compliance plan increases the threat of Qui tam lawsuits.  Indeed this act provides significant financial incentives for private citizens to come forward as whistleblowers.

In short, the Federal False Claims Act and anesthesia is a topic that cannot be taken lightly.  Anesthesia providers should be prepared with an active compliance plan.

Contact us for more information on these important topics and anesthesia compliance training for you and your company.  ACC Contact Us

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Learn about Mitigation in Compliance

Posted on Feb 15, 2017 in Compliance, Medicare Compliance

Mitigation in Compliance

What is Mitigation in Compliance?

Clients frequently ask us, what is “mitigation in compliance?” The answer comes straight from the dictionary, which states, “Mitigation is the action of reducing the severity, seriousness, or painfulness of something.”

Mitigating Outcomes

In the world of compliance, we do our best to stay out of the government’s crosshairs.  Despite our vigilance, there is always the chance something will go wrong and it may appear to the government you are billing incorrectly, raising the risk of false claims allegations.  To defend against this we recommend you adopt a compliance plan, perform audits and educate your staff.  By performing these activities, you can “mitigate” or lessen the probability that there will be an action against the group and lessen the severity of the penalties in the event one occurs.  Despite a recommendation from the Office of Inspector General to adopt the mitigation measures, anesthesia providers often forget the benefits they afford.

CMS makes this clear in their Compliance Policy and Guidance, which you can access below, in the active link.  Please review this to fully understand how you can be prepared for potential issues.

What You Can Do

When is the last time you reviewed your compliance plan, performed an audit and educated your staff?  We can help you “mitigate” by assisting you with the recommended compliance activities.

In addition you can get more information by following the link below:


Medicare Compliance Organization

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Coding the Physical Exam

Posted on Sep 9, 2016 in Billing, Compliance, Medicare Compliance


The physical examination is the objective portion of the patient encounter. The extent of the examination performed is determined by the patient’s medical condition and the nature of the current illness as recorded in the history.

There are four levels of examination:

Problem focused

Expanded problem focused



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E&M Coding-The History

Posted on Jul 2, 2016 in Billing, Compliance, Medicare Compliance

Today we will discuss how to code the History.

There are four levels of history recognized in CPT coding:

  • Problem Focused
  • Expanded Problem Focused
  • Detailed
  • Comprehensive

Reimbursement will depend on the level of history documented which I will describe in this tip.

A history is made of different parts and these elements are Chief Complaint, History of Present illness, Review of Systems, and Past Family and/or Social History
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