Fraud and Abuse Enforcement; Go Back to the Fundamentals

By: Stephen H. Siegel

The great basketball player Michael Jordon observed:

The minute you get away from fundamentals-whether it is proper technique, work ethic or mental preparation- the bottom can fall out of your game, your schoolwork, your job, or whatever you are doing.

In federal fiscal year 2016, the Department of Justice recovered $4.7 billion as the result of judgments and settlements under the Civil False Claims Act (“FCA”, the so-called “Whistleblower” statute). Over half of this amount, $2.5 billion, was collected from defendants involved in the healthcare industry. Paying attention to “fundamental” issues, such as coverage requirements, accurately billing for items and services rendered, and avoiding referral arrangements that implicate the Federal Kickback Prohibition or Self-Referral Restriction are fundamental aspects of doing business in this industry. However, as the issues, examples and lessons forgotten/ignored discussed below illustrate, there seems to be a significant gap between what should be and what certain healthcare providers and professionals actually are doing.

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