Healthcare professionals such as hospitals, urgent care centers and physicians who treat recipients of Medicare and Medicaid qualify to be reimbursed for the services they provide. As a way to eliminate incentives to make improper referrals that result in Medicare or Medicaid payments, anti-kickback laws were passed.
These laws are designed to prevent inappropriate payments from these government insurance programs. Enforcement attempts to curtail overutilization of medical services by a narrow group while preserving competition among healthcare providers. State and federal laws exist within anti-kickback legislation to carryout prohibited self-referrals.
Knowingly or willfully offering, paying, receiving or soliciting bribes, rebates or kickbacks in exchange for Medicare or Medicaid paid services can lead to criminal penalties.
The potential of liability for an anti-kickback violation abounds because there are many federal and states laws that address this issue. State self-referral prohibitions, which are similar to federal Stark regulations, are applicable to all types of payors and creates the potential of liability for health care providers.
These entities must also be aware of the corporate practice that governs medicine prohibitions. Many states have these and apply specific Medicare rules to different providers. Some examples that can cause problems for providers include set conditions for various entities for participating in the programs, licensure or certification standards and the Anti-Markup Rule.
Activities That Violate Anti-Kickback Law
Proof that a healthcare provider intentionally violated anti-kickback statutes to receive some type of compensation from Medicare or Medicaid is required. Examples of which activities raise suspicions of anti-kickback violations include:
• Receiving below the fair market rate for medical facilities in exchange for Medicare or Medicaid referrals
• When cash bonuses are given to a hospital from a diagnostic testing center or lab for Medicare and/or Medicaid patient referrals
• Referring physicians receive below market value patient care coordinating services to physicians
• Nursing homes receive pharmacy services from a pharmaceutical company after they offer monetary incentives to ensure the nursing homes use the company’s drug supplies for Medicare and Medicaid recipients
• Kickbacks are given to medical providers so a pharmaceutical company can increase its sales of a specific drug
• Medicare and Medicaid patients receive promotional offers from a drug store chain when they transfer their prescriptions to that store
• A nursing home receives free discharge planning from a hospice provider in exchange for referrals
Penalties for Violating Anti-Kickback Laws
There are severe criminal penalties for medical providers who violate federal anti-kickback laws. Some could receive a fine of up to $25,000, a five year prison sentence and even be excluded from future participation in either of these government insurance programs.
Civil cases also come with penalties. For each kickback violation, medical providers can be charged a fee as much as $50,000 per kickback. Violating these laws may also lead to a False Claims Act violation.
Permissible Safe Harbor Transactions
While healthcare providers across the industry are subject to high penalty violations, there are certain prohibited anti-kickback transactions that are permissible when meeting the standards of safe harbor regulations. Typically, these referrals involve:
• Academic surgical centers
• Affiliated health centers
• Ambulatory surgical centers
• Certain discounts
• Investment interests
• Items and services that are designated for HER
• Payments to legitimate employees
• Recruiting practitioners
A lawyer who is experienced with anti-kickback regulations on the state and federal level is the best consultant to know whether an action will lead to violating parts of the law. Providers should get clearance before entering into a referral situation or new business transaction.
Get San Diego Stark Anti-Kickback Lawyers on Your Side
At Raiser & Kenniff, PC, our dedicated San Diego Stark anti-kickback lawyers work with medical providers such as healthcare practice groups, hospitals and individual physician practices to make sure they maintain compliance with state and federal anti-kickback laws. We will also defend against any charges of violation that you may face.
Our experienced lawyers will help you draft compliance policies to ensure your medical service remains intact. We are on your side whether you need assistance with building a strong defense against civil or criminal anti-kickback violations or a program that helps you avoid this type of legal entanglement.
These are serious charges that can threaten the viability of your medical practice or hospital. Contact us today without delay.
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