Professional Documents
Culture Documents
3 18 15 Health Care Elunch PPT Final 150320170152 Conversion Gate01
3 18 15 Health Care Elunch PPT Final 150320170152 Conversion Gate01
3 18 15 Health Care Elunch PPT Final 150320170152 Conversion Gate01
Tom Mills
Marion Kristal Goldberg
March 18, 2015
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DOJ Qui Tam Recoveries in FY 2014
$2,300,000,000
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OIG Investigative Recoveries in FY 2014
$3,000,000,000
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OIG Audit Recoveries in FY 2014
$834,700,000
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Health Care Violations that Can Lead to
a False Claims Act Case
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Government Focus
Government Focus
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Government Focus
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Government Focus
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Government Focus
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Government Focus
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Government Focus
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Government Focus
• Insufficient documentation –
• Government view: If it’s not in the records, it
didn’t happen
• Can lead to refusal to pay
• Can lead to accusations of upcoding
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Government Focus
• Pharmaceutical companies
• Improper reporting for rebates
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Government Focus
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Government Focus
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Government Focus
• Quality of Care
• Long-term care provider
• $38 Million settlement
• Substandard care
• Inadequate staffing
• Failure to provide necessary services
• Failure to follow protocols
• Government alleged that care was so grossly
substandard that it was effectively worthless
• Medically unreasonable and unnecessary rehabilitation
services
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Recent Enforcement Actions
Exclusion
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Exclusion
• Mandatory Exclusion
• Felony conviction of criminal offense related to health
care
• Conviction of criminal offense related to patient neglect
or abuse
• Minimum 5 years
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Exclusion
• Permissive Exclusion
• Misdemeanor conviction for fraud or other financial
misconduct related to health care
• False claims
• Kickbacks
• Entity controlled by an excluded individual
• Individual who owns or controls an excluded entity
• Improper billing
• Failure to pay student loans
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Recent Enforcement Actions
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Recent Enforcement Actions
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Recent Enforcement Actions
• Florida Hospital
• $85 Million civil settlement
• Stark Law violations
• Bonuses to physicians were tied to referrals to
the hospital
• Above FMV payments to physicians
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Enforcement Actions
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Enforcement Actions
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Enforcement Actions
• Institutional pharmacy
• $124 Million settlement
• Government alleged company provided below
cost medication contracts for Part A patients in
return for referrals for drugs for patients under
Part D and Medicaid
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Enforcement Actions
• Dialysis provider
• $350 Million civil settlement
• Government allegations
• Company sold interests in Company-owned
dialysis centers to physicians at less than FMV
• Company purchased interests in physician-
owned dialysis centers from physicians at more
than FMV
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Enforcement Actions
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Enforcement Actions
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What You Should Be
Alerted To If You Are
A Health Care Company
Arrangements With Physicians
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Arrangements With Physicians
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Arrangements with physicians
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Arrangements With Physicians
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Arrangements With Physicians
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Arrangements – Other Referral Sources
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Arrangements – Other Referral Sources
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Joint Ventures With Physicians
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Joint Ventures With Physicians
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Joint Ventures With Physicians
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Joint Ventures With Physicians
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Compliance
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Compliance
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Compliance
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Compliance
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Compliance
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Compliance
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Coding
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Coding
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Coding
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What To Look For
In The Diligence
Process If You Are Investing,
Financing, or Underwriting
A Health Care Company
• Beware of a company that has found the way to
succeed in a field no one else has
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Arrangements With Referral Sources
and Referral Recipients
• Review contracts or a significant sample
• Is the contract commercially reasonable
• Is a party obligated to receive or provide more
than is required for the task
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Arrangements With Referral Sources
And Referral Recipients (cont'd)
• If the referral source is required to provide certain
services, does the referral recipient provide it at a
reduced cost or at no charge
• Is there a trade of one type of reimbursement for
another (e.g., low price for Part A items/services in
return for Part B items/services)
• If there are multiple contracts with the same
person, review them as a whole
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Contracts with Medical Directors
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Sales Contracts
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Joint Ventures
•Who gets to invest
•Does every investor have the same chance
to invest
•Do they require non-referrers to divest
•Are distributions paid in proportion to
ownership
•Are significant amounts invested compared
to distributions
•Is there real risk
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Acquisitions
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Investigations
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Committee Minutes
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Compliance
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Pharma And Device Manufacturers
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Quality Of Care
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If Numbers Are Important, Ask For
Them
• SNF – Percentage of patients with each number
of therapy days
• LTAC Hospitals – Average length of stay;
percentage of patients transferred from the host
hospital
• Hospice – Percentage of patients living more than
180 days
• IRF – Percentage of patients with qualifying
conditions
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Additional Issues
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Beware of
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Questions?
Thank You.
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