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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Fraud, Waste and Abuse

Posted on May 7, 2019 in Billing, Compliance, Medicare Fraud

Fraud, Waste and Abuse

Our Compliance Tip

We have heard much about Fraud, Waste and Abuse in the news lately and are aware the government has their eyes on the Anesthesia profession.   As providers of medical care we must be very familiar with these concepts. 

The Fraud, Waste and Abuse program has become very important and it is mandatory for healthcare professionals including Anesthesia Providers to understand the concepts.

Why It Is Important

Most important of all, the reason for this new required program is to help practitioners become aware of the significant problem we have today in terms of Medicare Fraud and Abuse.  Medicare abuse costs taxpayers billions of dollars and puts beneficiary’s health and welfare at risk.  In 2011 the US lost 3-10 % or $82-$272 billion annually due to healthcare fraud and abuse.

Fraud, and Intentional Action

Fraud is an intentional action that results in a benefit to the perpetrator.  The intention must be present for an action to be found to be a fraudulent activity.  In healthcare this may occur when services are not rendered or given in a matter claimed and they are intentionally billed.   A violation of the anti-kickback statute that results in reimbursement to the group can result in a false claims allegation by the OIG.  

Other actions can lead to allegations of false claims such as retention of overpayments, billing for services not provided or medically unnecessary, or up coding a claim, which uses a higher code than that which indicates the service rendered. An example of up coding is using a code with a higher amount of base units than that performed.  Unbundling services breaks apart elements into separate items of a service that we normally bill together.  There have been cases where an anesthesiologist unbundled provision of oxygen and basic monitoring from basic anesthesia care to bill for them separately. 

Examples of Fraud

Examples of fraud that show intent to defraud include: documenting a service that did not occur, upgrading the physical status, submitting documentation for reimbursement that you know is not correct and creating false documentation to support a higher level of service. 

What is Abuse

Primarily the term abuse means practices that are not consistent with medical, business or financial standards that result in waste of funds for reimbursement.  The government often links this with fraud.  

As an example of abuse is billing non-covered services as covered services, reporting duplicate charges on a claim, charging excessively for services, and improper billing that results in payment by a government program when another payer is responsible.

Most important of all CMS requires all providers to know how to combat fraud and abuse.  Providers must also learn how to keep their organizations from engaging in abusive practices that hurt the Medicare program.

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Detecting Health Fraud

Posted on Mar 21, 2016 in Billing, Compliance, Medicare Fraud

The main tools for detection of fraud and abuse were traditionally through whistleblowers who took information of a suspicious practice to the government.  This tool is still used, but electronic audits and monitoring are now playing a large role in fraud detection.  Usually, with either type of investigation you won’t know you are under investigation until the government unveils its case against you.  For some groups this is after many years of investigation and evidence collection.  With electronic means to review your claims for up to the last 10 years the risks are very high for anesthesia providers

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