1. Disclaimer
This presentation is intended only for use by Tulane University faculty, staff, and students. No copy or use of this presentation should occur without the permission of Tulane University. Tulane University retains all intellectual property interests associated with the presentation. Tulane University makes no claim, promise, or guarantee of any kind about the accuracy, completeness, or adequacy of the content of the presentation and expressly disclaims liability for errors and omissions in such content.
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2. Overview of Health Care Laws
TUMG Compliance Training
Anti-Kickback
False Claims Act
Stark Laws
Sarbanes-Oxley
Print the Overview of Health Care Laws Quiz before viewing presentation
Overview of Health Care Laws
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3. Read Before Proceeding
Physicians and Staff may earn one compliance credit by viewing this presentation, completing the assessment, and faxing the assessment to the
University Privacy and Contracting Office:
This presentation may be viewed for compliance credit only once in a fiscal year (July 1 - June 30).
To check how many compliance credits you have and to see which training sessions you have completed, contact the University Privacy and Contracting Office at
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4. It is the policy of TUMG to provide healthcare services that are in compliance with all state and federal laws governing its operations and consistent with the highest standards of business and professional ethics. Education for all TUMG physicians is an essential step in ensuring the ongoing success of compliance efforts.
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5. The other general compliance education presentations are:
This education is a General Compliance Education Presentations available on the Tulane University Privacy and Contracting website:
The other general compliance education presentations are:
Fraud and Abuse
TUMG Documentation Top 10
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6. Purpose of Presentation
Health Care law is expanding. Health care entities and providers must keep abreast of the latest regulations.
This presentation will provide a brief overview of four laws that pertain to healthcare practices
Anti-Kickback Statute
False Claims Act
Stark Laws
Sarbanes-Oxley
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7. The Federal Health Care Anti-Kickback Statute
(Social Security Act §1128B(b), 42 U.S.C. §
1320a-7(b))
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8. What is the scope of the Statute?
The Anti-kickback Statute is an “extremely broad criminal statute which provides penalties for individuals or entities that knowingly and willfully offer, pay, solicit or received remuneration in order to induce business for which payment may be made, in whole or in part, by a Federal health care program, including the Medicare and Medicaid programs.”
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9. Remuneration includes but is not limited to:
Kickbacks,
bribes,
and rebates
made directly or indirectly,
overtly or covertly,
in cash or in kind
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10. Examples of Anti-Kickback Violations
Cash for patients: giving cash in exchange for the referral of patients covered by a Federal Health Care program
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11. Examples of Anti-Kickback Violations
Waivers of co-pays and deductibles: The routine waiver of Medicare Part B co-payments and deductibles violates the Anti-Kickback Statute.
Nah…we don’t need your co-pay
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12. OIG position on Waivers of Co-pays and/or Deductibles
In addition to the Anti-Kickback Statute, the OIG (Office of the Inspector General) says that a provider, practitioner or supplier who routinely waives Medicare co-payments or deductibles is misstating its actual charge.
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13. Waivers of Co-pays and Deductibles have consequences
For example, if a supplier claims that its charge for a piece of equipment is $100, but routinely waives the $20 co-payment, the OIG considers that the actual charge is $80.
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14. Waivers of Co-pays and Deductibles
Medicare should be paying 80% of $80 ($64) rather than 80% of $100 ($80).
As a result of the supplier’s misrepresentation of the charge, the Medicare program is paying $16 more than it should for this item
In addition, the Medicare recipient should be paying a lower co-pay.
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15. Examples of Anti-Kickback Violations
Medical Director agreements: If compensation is paid, even in part, for referrals covered by a Federal health care program, the Anti-Kickback statute may be violated.
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16. Anti-Kickback Indictments
Source: “This Week in Corporate Compliance” Vol. VI, No. 28 – August Published by the Health Care Compliance Association
Anti-Kickback Indictments
On August 4, [2004] US Attorney for the Southern District of Florida, Marcos Daniel Jiménez, announced the unsealing of a 324 count Indictment in Fort Lauderdale, Florida. Fourteen defendants... are charged with participating in a scheme to defraud Medicare of over $8 million. If convicted, the defendants face various statutory maximum sentences ranging from five (5) years’ imprisonment to twenty (20) years’ imprisonment per count, and face fines of up to $16 million.
The Indictment alleges that three therapy companies …paid kickbacks to assisted living facilities and to patient recruiters for access to patients.
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17. Penalties for Anti-Kickback Violations
Violation of the anti-kickback laws is a felony, punishable by a $50,000 fine plus three times the amount of remuneration paid, or imprisonment up to five years, or both.
Violation of the law could also mean the TUMG and/or a TUMG physician or other clinician is excluded from participating in the Medicare and Medicaid programs for up to five years.
Source: Tulane University Health Care Compliance Policy Manual
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18. The False Claims or Qui Tam Act
Signed into law in 1863 during Abraham Lincoln’s term of office, the False Claims Act was significantly changed in 1986 to make it a more effective tool for prosecuting and obtaining judgments for filing false or fraudulent claims.
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19. The False Claims Act applies when a person or company:
Conspires with others to get a false or fraudulent claim paid by the Federal Government
Knowingly uses (or causes to be used) a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the Federal Government.
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20. The False Claims Act applies when a person or company:
Knowingly uses (or causes to be used) a false record or statement to get a claim paid by the Federal Government
Knowingly presents (or causes to be presented) to the Federal Government a false or fraudulent claim for payment.
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21. Lawsuits filed under the False Claims Act are often referred to as “Whistleblower” lawsuits.
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22. The False Claims Act allows everyday people to bring suits against groups or individuals that are defrauding the government through programs, agencies or contracts
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23. Statute of Limitations for False Claims
Suits under the False Claims Act can be brought (whichever is the later date):
Within six years from the date of the illegal conduct, or
Within three years after the Government knows or should have known about the illegal conduct, but in no event later than ten years after the illegal activity.
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24. What Money Can Be Recovered?
A person who initiates a False Claims Act lawsuit is entitled to a proportional share of the funds recovered for the government.
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25. Protections for People Who Bring False Claims Act Cases
The False Claims Act protects anyone who lawfully acts in investigation of, initiation of, testimony for, or assistance in a False Claim.
The individual is protected against
discharge, demotion,
suspension, threats,
harassment, and discrimination.
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26. What Kinds of False Claims Cases Are Filed?
Originally, most claims were against companies involved in the Military or Defense Industry.
Over time, the focus shifted to health care companies.
Now the source of claims is becoming more and more diverse.
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27. False Claims Settlements
Downey Regional Medical Center Settlement Announced On August 18, (2004) US Attorney for the Central District of California Debra W. Yang announced that Downey Regional Medical Center (DRMC), a 200-bed hospital located in Downey, California, has paid the United States more than $2.2 million to resolve allegations that the hospital submitted false claims to Medicare, the taxpayer-funded health care insurance program for many of the nation’s elderly and disabled. The settlement amount - which totaled $2,220,060 - is two times the loss suffered by the Medicare program.
Source: “This Week in Corporate Compliance,” Vol. VI, No. 30 – August 24, 2004, Health Care Compliance Association Publication
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28. False Claims Conviction
On March 3, [2005] US Attorney for the Southern District of Florida Marcos Daniel Jiménez announced that two defendants were convicted by a federal jury, after a three-week trial… in Miami, Florida, bringing the total number of convictions to twelve (12), in a multi-million dollar Medicare fraud and money laundering scheme involving local durable medical equipment (DME) companies that fraudulently submitted false claims to Medicare with respect to expensive custom-made orthotic devices such as knee, shoulder, and hip braces.
Source: “This Week in Corporate Compliance,” Vol. VII, No.8–March 10, 2005 Health Care Compliance Association Publication
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29. False Claims Settlements
Source: “This Week in Corporate Compliance, Vol. VI, No. 35 – October 4, 2004, Health Care Compliance Association Publication
False Claims Settlements
On September 29 [2004] the Seattle Post-Intelligencer reported that the “University of Washington has lifted its objection to unsealing federal records compiled during a nearly five-year investigation into medical school billing practices.”
”The records have been sealed since 1999, when a whistle-blower lawsuit sparked the Justice Department investigation. In the suit, former UW employee Mark Erickson accused the medical school of intentionally over billing Medicare and Medicaid.”
”In April, the university paid $35 million to settle the suit and some records were unsealed.”
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30. Stark Laws
Stark Laws, Phases I and II, pertain to physicians’ referrals to health care entities with which they have financial relationships.
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31. Stark Laws
The Stark Laws incorporate provisions of the Social Security Act into Medicare regulations
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32. Section 1877 of the Social Security Act prohibits physicians from referring Medicare patients for certain designated health services (DHS) to an entity with which the physician or a member of the physician’s immediate family has a financial relationship unless an exception applies.
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33. Section 1877 also prohibits an entity from presenting, or causing to be presented, a bill or claim to anyone for a DHS furnished as a result of a prohibited referral.
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34. Phase I of the Stark Laws
Addresses section 1877 of the Social Security Act, paragraphs (a) and (b) regarding the general prohibition and the exceptions applicable to both ownership and compensation arrangements.
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35. Phase II of the Stark Laws
Addresses statutory exceptions related to ownership and investment interests, the statutory exceptions for certain compensation arrangements, and the reporting requirements.
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36. Source: “This Week in Corporate Compliance,” Vol. VI, No
Source: “This Week in Corporate Compliance,” Vol. VI, No. 28 – August , Health Care Compliance Association Publication
Recent Stark Case
On August 6, [2004] US Attorney for the Eastern District of Pennsylvania Patrick Meehan announced a civil settlement between the United States of America and Leonard Ginsburg, M.D., Moore Eye Care, Retina and Diabetic Eye Specialists, ….that resolves alleged violations of the Stark law and the anti-kickback statute. This civil settlement arose out of a qui tam suit filed by a former office administrator for the Moore Eye Institute.
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37. Sarbanes-Oxley (SOX) Act of 2002
The purpose of the Sarbanes-Oxley Act is “To protect investors by improving the accuracy and reliability of corporate disclosures made pursuant to the securities laws, and for other purposes.”
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38. Sarbanes-Oxley Act of 2002
Of the four laws discussed in this presentation, Sarbanes-Oxley is the newest.
It was enacted in response to recent financial disasters such as ENRON.
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39. Health Care Company the first to test the new law
The Founder and Chief Executive of Health South Corp., Richard Scrushy, was the first individual indicted under the Sarbanes-Oxley law.
Scrushy was found not-guilty on all indictments against him.
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40. Overview of SOX Signed into law July 30, 2002.
The most dramatic change to federal securities laws since the 1930’s.
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41. Sarbanes-Oxley:
Radically redesigns federal regulations of public company corporate governance and reporting obligations.
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42. Sarbanes-Oxley:
Significantly tightens accountability standards for directors and officers, auditors, securities analysts and legal counsel.
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43. Key Change
As of April 26, 2003, the SEC has directed the NYSE and NASDAQ to prohibit listing any public company whose audit committee does not comply with new requirements regarding auditor appointment, compensation and oversight.
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44. Sarbanes-Oxley will have direct impact on any public health care company
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45. Summary
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46. Anti-Kickback Statute
Three areas of direct risk for providers
Cash for patient referrals (either giving or receiving remuneration)
Waiver of co-pays and deductibles
Medical Director Agreements
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47. False Claims Act
Often referred to as Whistleblower or “Qui Tam” lawsuits
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48. False Claims Act Violations involve: Knowingly filing fraud claims
Knowingly submitting a fraudulent record or statement to receive payment for a claim
Knowingly conspiring with others to get a fraudulent claim paid by the government
Knowingly using (or causing to be used) a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the Federal Government
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49. Stark Laws, Phases I and II
pertain to physicians’ referrals to health care entities with which they have financial relationships.
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50. Sarbanes-Oxley:
New Law (2002) which addresses issues regarding financial reporting and responsibilities of boards of public companies.
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51. Go to the Source
The following sources were consulted for this presentation:
History of Federal Anti-Kickback Statute
Health Insurance Portability and Accountability Act of 1996
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52. Go to the Source http://www.cpeonline.com/cpenew/sarox.asp
Sarbanes-Oxley Act of 2002
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53. Go to the Source
Physician’s Referrals to Health Care Entities With Which They Have Financial Relationships
The False Claims or Qui Tam Act
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54. Go to the Source
Criminal Penalties For Acts Involving Federal Health Care Programs
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55. TUMG Business Services Compliance Reporting Hotline: 504-988-5142
Know who to contact:
TUMG Business Services
Compliance Reporting Hotline:
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56. Complete and Sign the “Overview of Health Care Laws” Quiz
End of Presentation
To Earn Compliance Credit:
Complete and Sign the “Overview of Health Care Laws” Quiz
Fax to:
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