Program Integrity and Fraud Abuse

Together, the Centers for Medicare and Medicaid Services (CMS), the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS), and the Department of Justice (DOJ), are responsible for the implementation and enforcement of program integrity laws. These laws include the:

  • Physician Self-Referral Law (Stark Law)
  • Medicare anti-kickback Statute (AKS)
  • False Claims Act (FCA)
  • Exclusion Authorities
  • Civil Monetary Penalty Law (CMP)

Hospitals operate under compliance programs that seek to ensure they work within the parameters of these laws.  However, while these laws primarily have been enacted to address wrongdoing, their breadth may impact the honest business practices of providers due to ambiguities in the laws and regulations.

Because hospitals regularly engage in business operations and arrangements that may implicate these program integrity laws, it is critical that hospitals stay informed about the application of these laws. Violations of the laws could result in criminal penalties, civil fines, exclusion from federal health care programs, or loss of a hospital’s Medicare provider agreement.

The FAH advocates on behalf of investor-owned hospitals to ensure bright lines when possible, and to mitigate burdensome or unnecessary technical enforcement interpretations of these laws. We also seek to ensure that the focus of these laws is educational, rather than unnecessarily punitive, and that any potential penalties are structured to reflect inadvertent technical violations. Recent, key FAH advocacy efforts in this regard include:

Prohibiting self-referral to physician-owned specialty hospitals, which increase costs to the Medicare program and shift risk and costs to community hospitals;

  • Streamlined and simplified penalty structure for technical non-compliance with the Stark Law;
  • Development of a streamlined and simplified Self-Referral Disclosure Protocol (SRDP);
  • Development of new and revised AKS safe harbors to promote:
  • Access to, and coordination of team-based care;
  • Interoperability of health information technology; and,
  • Patient compliance and preventive care, and value-based care
  • Revisions to the CMP Law to allow more flexibility for provider integration and discretion in offering services to beneficiaries that promotes patient compliance, preventive care, and the delivery of value-based care.