Our firm provides clients with legal interpretation and analysis in the areas of fraud and abuse and Stark Laws. For example, we often analyze potential structures for joint ventures and other healthcare business structures.

Stark Law Issues - The Federal Stark Law prohibits physicians that have a financial relationship with an entity from making referrals to the entity for the furnishing of certain designated health services for which payment is made by the Medicaid or Medicare program. However, there are certain exceptions to the Stark law that, if strictly followed, would allow for arrangements that would otherwise be prohibited. Our firm can assist your practice with the review of certain business transactions that may implicate the Stark law.

Most Medicare payment errors are simple mistakes and are not the result of physicians, providers, or suppliers trying to take advantage of the Medicare system.

Medicare is taking strong action to combat fraud and abuse of the system in key areas. Their goal is to make sure Medicare only does business with physicians, providers, and suppliers who will provide people with Medicare with high quality services.

The effort to prevent and detect fraud is a cooperative one that involves:

The Centers for Medicare & Medicaid Services (CMS)
People with Medicare
Providers of Medicare services including physicians, providers, and supplier,
State and Federal Agencies such as, the Department of Health and Human Services Office of the Inspector General, the Federal Bureau of Investigation (FBI), and the Department of Justice.

Fraud and abuse are widespread and very costly to America's health-care system. Fraud involves intentional deception or misrepresentation intended to result in an unauthorized benefit.

An example would be billing for services that are not rendered. Abuse involves charging for services that are not medically necessary, do not conform to professionally recognized standards, or are unfairly priced. An example would be performing a laboratory test on large numbers of patients when only a few should have it. Abuse may be similar to fraud except that it is not possible to establish that the abusive acts were done with an intent to deceive the insurer.

Type of Fraud and Abuse

False claim schemes are the most common type of health insurance fraud. The goal in these schemes is to obtain undeserved payment for a claim or series of claims. Such schemes include any of the following when done deliberately for financial gain:

Billing for services, procedures, and/or supplies that were not provided.
Misrepresentation of what was provided; when it was provided; the condition or diagnosis; the charges involved; and/or the identity of the provider recipient.
Providing unnecessary services or ordering unnecessary tests.

Florida Anti-kickback:

Anti-kickback Issues- Physicians and other health care providers are required to comply with numerous laws and regulations related to the provision of health care services. One such law is the Federal anti-kickback statute which provides for criminal as well as civil monetary penalties for violations. Our firm can assist your practice with the review of certain business transactions that may implicate the anti-kickback statute.

Kickbacks: Receiving payment or other benefit for making a referral. Indirect kickbacks can involve overpayment for something of value. For example, a supplier whose business depends on physician referrals may pay excessive rent to physicians who own the premises and refer patients. Another example would be a mobile testing service that performs diagnostic tests in a doctor's office. Kickbacks can distort medical decision-making, cause over utilization, increase costs, and result in unfair competition by freezing out competitors who are unwilling to pay kickbacks. They can also adversely affect the quality of patient care by encouraging physicians to order services or recommend supplies based on profit rather than the patients' best medical interests. In 2000, the Office of the Inspector General issued a fraud alert warning against kickbacks disguised as rental payments.