AHLA Fraud and Abuse Investigations Handbook for the Health Care Industry (AHLA Members)
This second edition of Fraud and Abuse Investigations Handbook for the Health Care Industry provides not only the legal context surrounding health care fraud investigations, but also the insight critical to managing the process—and potentially the outcomes that follow. It is ideal for health care administrators, executives, medical directors, office managers, and physicians who need to arm themselves with a broad understanding of Fraud and Abuse enforcements.
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The quest to stamp out fraud, waste, and abuse in the nation’s health care system has drawn dramatically increased scrutiny of health care billing and reimbursement practices over the years. For those involved in this heavily regulated industry, understanding the powers, procedures, and remedies available to the government during an investigation is paramount. This Second Edition of Fraud and Abuse Investigations Handbook for the Health Care Industry provides not only the legal context surrounding health care fraud investigations, but also the insight critical to managing the process—and potentially the outcomes that follow.
The American Health Law Association and Authors Paul W. Shaw and Robert A. Griffith have revised this necessary Handbook, bringing not only their prior experience as prosecutors, but also decades of experience as private practitioners representing health care businesses and professionals under federal and state criminal and civil fraud and abuse investigations. The Authors examine each stage of a fraud and abuse investigation, beginning with an overview of federal and state enforcement agencies, and concluding with a discussion of the potential collateral consequences of an investigation. They have supplemented their analysis extensively with sample documents, including indictments, requests for records, subpoenas, internal response memoranda, and responses to auditors, prosecutors, and more. Taken together, the materials in this book provide a true Handbook for anyone who needs to quickly and thoroughly understand the complex nature of a government fraud and abuse investigation.
Highlights of the expanded and updated coverage in this Second Edition include:
- Critically important changes in the handling of mandated and voluntary disclosures of overpayments, a result of regulatory activity since the first edition:
- The Final 60-Day Overpayment Rule
- The Revised Stark Self-Disclosure Protocol
- Department of Justice voluntary disclosure guidelines for False Claims Act cases
- A chapter on responding to Medicare and Medicaid audits and initiating appeals, with insight into the post payment audit process, practical advice on how to respond to a request for records or audit findings, and a description of each step of the appeal process, including settlement procedures
- A chapter on administrative sanctions, discussing the potential risk of sanctions under the Civil Monetary Penalties law, exclusion from Medicare and/or Medicaid, mandatory vs. permissive exclusion, due process, Medicare and Medicaid program payment suspensions, enrollment denials, and revocations
- A chapter on audits by private payers, examining audit-generating conduct and how to respond to a private payer audit and findings
- A chapter on the collateral consequences that may follow a health care fraud and abuse investigation, including impact on private health insurance participation, state medical board licenses, and more
Also with this edition, readers are invited to download 30 of the more than 85 exhibits included in this book, and adapt them to suit their own practice and client needs.
The 1st Edition ISBN was 9780769865720.
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Published April, 2021.
Table of contents
Chapter 1. Introduction
Chapter 2. Overview of Enforcement Agencies
Chapter 3. The Statutory Framework for Fraud and Abuse Investigations
Chapter 4. Requests for Information, Investigatory Demands, and Subpoenas
Chapter 5. Responding to Requests for Information
Chapter 6. Handling On-Site Demands for Records and Access
Chapter 7. Retaining Attorneys and Professionals During an Investigation
Chapter 8. Postpayment Audits Using Statistical Sampling
Chapter 9. Responding to Medicare/Medicaid Audits and Initiating Appeals
Chapter 10. Audits by Private Payers
Chapter 11. Internal Audits and Investigations
Chapter 12. Mandated and Voluntary Disclosures of Overpayments
Chapter 13. Administrative Sanctions
Chapter 14. Prejudgment Remedies and Criminal Forfeiture
Chapter 15. Criminal and Civil Settlements
Chapter 16. Collateral Consequences of a Fraud and Abuse Investigation