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Summary of Federal and Abuse Laws

These laws include Health Care Fraud (18 U.S.C Section 1347), False Statements

relating to Healthcare Matters (18 U.S.C Section 1035), Theft & Embezzlement in

Connection with Health Care Benefit Program 18 (U.S.C. Section 669), False Claims Act (18

U.S.C. Section 287), and Fraud (18 U.S.C. Sections 1341 and 1343) (Wolper, 2012).

Additional laws include Medicare & Medicaid Patient Protection Act of 1987 (42 U.S.C.

Section 1320a-7b (a)), Medicare & Medicaid Patient Protection Act, Obstruction of Criminal

Investigations of Health Care Offenses (18 U.S.C Section 1518), Anti-kickback Statute (42

U.S.C. Section 1320a-7(b)), State Criminal Laws, and Civil & Administrative Statutes, and

Federal Physician Self-Referral Prohibitions (The Stark Law). Risk areas focused on during

physician investigations include coding and billing, reasonable and necessary services,

documentation, improper inducements, kickbacks, and self-referrals.

Implementing and Operating Physician Practice Compliance Program

Physician practice compliance entails delegation, responsibility, and authority,

whereby managers delegate responsibilities and authority to execute tasks that help achieve

organizational goals (Wolper, 2012). The various activities of physician practice include

planning, controlling, evaluation, and feedback. Planning comprises strategic, long-term, and

operational planning. Controlling consists of policies that ensure efficient use of resources,

development of standards, and employee motivation. Evaluation and feedback involve

qualitative and quantitative methods for assessing whether the procedures and controls that

have been established have resulted in the achievement of the program’s goals (Wolper,

2012). In addition, human resource management involves human resources planning,

employment, induction and orientation, management and employee training and

development, and health and safety.

The elements of compliance plans and programs include evaluating the size of a

practice, with key determinants including total practice revenues, Medicare receipts,

operational expenses, physician numbers, and organizational complexities. Elements to

address management issues include standards of conduct & policies and procedures,

designation of a compliance officer, conducting effective training and effective lines of

communication, auditing and monitoring, establishing disciplinary guidelines, and

responding to detected offenses.

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1 Summary Summary of Federal and Abuse Laws These laws include Health Care Fraud (18 U.S.C Section 1347), False Statements relating to Healthcare Matters (18 U.S.C Section 1035), Theft & Embezzlement in Connection with Health Care Benefit Program 18 (U.S.C. Section 669), False Claims Act (18 U.S.C. Section 287), and Fraud (18 U.S.C. Sections 1341 and 1343) (Wolper, 2012). Additional laws include Medicare & Medicaid Patient Protection Act of 1987 (42 U.S.C. Section 1320a-7b (a)), Medicare & Medicaid Patient Protection Act, Obstruction of Criminal Investigations of Health Care Offenses (18 U.S.C Section 1518), Anti-kickback Statute (42 U.S.C. Section 1320a-7(b)), State Criminal Laws, and Civil & Administrative Statutes, and Federal Physician Self-Referral Prohibitions (The Stark Law). Risk areas focused on during physician investigations include coding and billing, reasonable and necessary ...
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