All UBMD employees are required to work in compliance with all applicable laws, rules & regulations. Failure to do so may result in civil and/or criminal violations, leading to exclusion, monetary fines and/or imprisonment. Below are some laws and regulations all UBMD employees should be familiar with.
Guidelines developed by the U.S. Sentencing Commission, an independent agency in the judicial branch of government established by the 1984 Sentencing Reform Act, to govern the sentencing of individual defendants (1987) and organizations (1991).
The CMPL authorizes the OIG to seek CMPs and sometimes exclusion for a variety of health care fraud violations. Different amounts of penalties and assessments of up to three times the amount claimed for each item or service, or up to three times the amount of remuneration offered, paid, solicited or received. Violations that may justify CMPs include:
HIPAA is a federal law, with civil and criminal penalties of up to $1,500,000. UBMD has a separate, detailed set of privacy, security and breach notification rules, policies and procedures, and all employees are directed to reference those policies and procedures, for more comprehensive guidance.
For more detailed information on HIPAA, visit our HIPPA page.
The 21 Century Cures Act, more widely known simply as the Cures Act, has many important components to it affecting health care delivery. Also often referred to as Information Blocking, the new act includes efforts to increase patient access to their health information and remove obstacles patients encounter when trying to access their own electronic health information. From this, provider notes from all encounters, lab results and radiology and pathology reports are to automatically be available in the patient portal.
This policy applies to all UBMD practice plans who bill government programs including, without limitation, Medicare and Medicaid. Federal and state governments require healthcare providers to check the names of all providers, staff and agents/vendors against exclusionary databases. It is required that each UBMD practice plan check the following exclusionary databases (“Exclusionary Databases”) according the time frames listed below:
The following Exclusionary Databases must be checked monthly:
The following Exclusionary Databases must be checked against providers only when a provider is credentialed or re-credentialed:
If a match is found on any exclusionary database, the provider, staff member or agent/vendor should be immediately suspended. That person should be given the opportunity to appeal to the appropriate government agency to have his or her name removed from the Exclusionary Database or receive a waiver from the appropriate government agency.
If those actions are not successful, provider or staff member must be terminated from employment and the contract with the agent/vendor must be terminated.
The Physician Self-Referral Law, also known as the Stark Law, is a federal law which prohibits any physician from referring patients for the provision of “designated health services” to any entity with which the physician or an immediate family member has a financial relationship, unless a statutory exception applies.
“Designated health services” are any of the following:
If a financial relationship exists, referrals are prohibited unless a specific exception is met for both the federal and state statutes. The federal and state exceptions differ in some cases; therefore, physicians are advised against relying on the exceptions without first consulting with the UBMD Compliance Officer and/or legal counsel.
The Federal Antikickback Statute makes it a crime to knowingly and willfully offer, pay, solicit, or receive any remuneration directly or indirectly to induce or reward patient referrals or the generation of business involving any item or service reimbursable by a Federal health care program.
Examples of kickbacks include waiving deductibles and copayments for Medicare patients, paying a nurse practitioner or physician a fee for referring a patient, accepting a fee for referring a patient. Remuneration includes anything of value, such as cash, free rent, expensive hotel stays and meals, and excessive compensation for medical directorships or consultancies.
There are safe harbors that protect certain payment and business practices; however, to be protected by a safe harbor, an arrangement must satisfy all of the safe harbor’s requirements.
The Antikickback Statute is a criminal statute and, therefore, includes jail time as one of its penalties. Physicians who pay or accept kickbacks also face penalties of up to $50,000 per kickback plus three times the amount of the remuneration. Providers and their employees are prohibited from accepting kickbacks in the course of business. Additionally, providers and their employees are required to contact legal counsel or the UBMD Compliance Officer before accepting a gift or any item of value relating to or arising from UBMD business, provider relationships or medical office operations.
For more information: 42 U.S.C. Section 1320a-7b(b)
For more information on safe harbors: Safe Harbor Regulations and 42 Code of Federal Regulations (C.F.R.) Section 1001.952
The False Claims Act is a federal statute which prohibits health care providers from “knowingly” presenting, or causing to be presented, a false or fraudulent claim for payment or approval to any federally funded program, such as Medicare and Medicaid.
The term “knowingly” does not simply refer to a specific intent to defraud the federal government. To “knowingly” present a false claim means that the provider:
Violations of the FCA may result in monetary penalties equal to three times the government’s damages plus civil penalties of $5,500-$11,000 per false claim. Criminal cases may include imprisonment. Health care providers may also be excluded from participation in federal health care programs.
For more information: False Claims Act
The Exclusion Statute requires the OIG to exclude individuals and entities from all Federal health care programs if they are convicted of the following criminal offenses:
They also impose permissive exclusions for other reasons, including:
Excluded providers may not participate in the Federal health care programs for a designated period. If you are excluded by OIG, then Federal health care programs, including Medicare and Medicaid, will not pay for items or services that you furnish, order, or prescribe. Excluded providers may not bill directly for treating Medicare and Medicaid patients, and an employer or a group practice may not bill for an excluded provider’s services. At the end of an exclusion period, an excluded provider must seek reinstatement; reinstatement is not automatic.
For the UBMD Compliance Plan policy regarding checking for excluded providers please visit: Section V (G) Monitoring Exclusionary Databases.
The Deficit Reduction Act of 2005 states that any employer who receives more than $5 million per year in Medicaid payments is required to provide information to its employees about the federal False Claims Act, any applicable state False Claims Act, the rights of employees to be protected as whistleblowers, and the employer’s policies and procedures for detecting and preventing fraud, waste and abuse.