What is AKS in healthcare?

The federal Anti-Kickback Statute (AKS) (See 42 U.S.C. § 1320a-7b.) is a criminal statute that prohibits the exchange (or offer to exchange), of anything of value, in an effort to induce (or reward) the referral of business reimbursable by federal health care programs.

What is a referral under the AKS?

The Seventh Circuit's Expansive Construction of 'Referral'

An AKS conviction requires the government to prove that a defendant: (1) knowingly and willfully (2) solicited or received remuneration (3) in return for (4) a referral (5) of business reimbursable by a federal healthcare program.

What is the difference between the Stark Law and the AKS?

The Anti-Kickback Law covers referrals for all services from anyone including physicians or pharmaceutical companies. Conversely, the Stark Law is for referrals from physicians only and covers a set list of “Designated Health Services” (DHS).

What is the penalty for violating the AKS?

Criminal penalties and administrative sanctions for violating the AKS include fines, jail terms, and exclusion from participation in the Federal health care programs. Under the CMPL, physicians who pay or accept kickbacks also face penalties of up to $50,000 per kickback plus three times the amount of the remuneration.

Who does the Anti-Kickback Statute apply to?

The Anti-Kickback Statute, 42 U.S.C. § 1320a-7b(b), covers a broader range of activity than the Stark Law, and extends to all medical providers in a position to arrange or recommend medical services.

The New AKS and Stark Laws Final Rules Key Take Aways

What is considered a kickback in healthcare?

It's simple to define what kickbacks in health care are. If a physician or medical provider uses any payment or compensation to encourage a patient to come to their office, or to encourage another medical provider to refer patients to their office or facility, that is a kickback.

What is an example of a kickback?

Frequency: The definition of a kickback is slang for a bribe or incentive paid to someone who helped you make money, or a sudden, forceful recoil. When you bid on a job and job is awarded to you and you have to pay someone $1000 because your received the award, this $1000 payment is an example of a kickback.

What is considered to be an illegal provider relationship?

Which of the following is considered to be an illegal provider relationship? Any person or entity who knows, or should have known, of the presentation of a false or fraudulent claim to the government for payment or approval is subject to .

What is a false claim in healthcare?

Examples of false claims include billing for services not provided, billing for the same service more than once or making false statements to obtain payment for services. Penalties Under the False Claims Act. Violations under the federal False Claims Act can result in significant fines and penalties.

What is Medicare abuse?

Abuse describes practices that may directly or indirectly result in unnecessary costs to the Medicare Program. Abuse includes any practice that does not provide patients with medically necessary services or meet professionally recognized standards of care.

Do doctors get kickbacks for referrals?

The Stark law prohibits a physician from referring patients for services in which the doctor has a financial interest. The federal anti-kickback statute bars hospitals from paying doctors for referrals.

Who does Stark Law protect?

The Stark law prohibits a physician's referral for certain designated healthcare services (DHS) to an entity if the physician (or a member of the physician's immediate family) has a financial relationship with the entity, unless the referral is protected by one or more exceptions provided in the law.

Why is the Stark Law important?

The Stark Law matters because it tried to fight a very insidious erosion of the foundation of the trust between a doctor and patient. But the Stark Law also matters because patients and the American taxpayers wind up footing the bill for the bribery.

Why is the Anti-Kickback Statute important?

At its heart, it is an anti-corruption statute designed to protect federal health care program beneficiaries from the influence of money on referral decisions and thus is intended to guard against overutilization, increased costs, and poor quality services.

How do you prevent Anti-Kickback Statute?

What are the Anti-Kickback safe harbors?

Anti-Kickback Laws and Safe Harbor Regulations

The safe harbor regulations define payment and business practices that will not be considered kickbacks, bribes, or rebates that unlawfully induce payment by Medicare or Medicaid programs.

What is the Red Flags Rule healthcare?

The Red Flags Rule requires that organizations have “reasonable policies and procedures in place” to identify, detect and respond to identity theft “red flags.” The definition of “reasonable” will depend on your practice's specific circumstances or specific experience with medical identity theft as well as the degree ...

What is the qui tam provision?

Under the False Claims Act, qui tam allows persons and entities with evidence of fraud against federal programs or contracts to sue the wrongdoer on behalf of the United States Government. In qui tam actions, the government has the right to intervene and join the action.

What is an example of the False Claims Act?

Examples include people who lie to Medicare or Medicaid, facilities that bill for services they did not provide, or those that inflate the cost of the services they did get. They may even lie about who is providing services. The company bills the government for skilled professionals but uses non-professionals instead.

What 5 elements must exist for a Stark Law violation to occur?

In order for a relationship to implicate Stark, five basic elements must be present: (1) a physician must make (2) a referral for the furnishing of (3) designated health services payable by Medicare (4) to an entity (5) with which he/she (or an immediate family member) has a financial relationship.

What can cause a false claim to occur?

Liability under the federal False Claims Act occurs when a defendant (1) knowingly presents (or causes to be presented) a false or fraudulent claim for payment; (2) knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim; (3) conspires with others to ...

What is double billing in healthcare?

Double billing: This happens when the same bill is submitted multiple times when the procedure was performed only once.

How do kickbacks work?

Key Takeaways. A kickback is an illegal payment intended as compensation for preferential treatment or any other type of improper services received. Kickbacks are often referred to as a type of bribery. While kickbacks can take many different forms, they all feature some sort of collusion between two parties.

How do you identify a kickback?

To identify kickbacks, security services often use frontline methods such as test purchases . During the checkout, the "buyer" proposes a rollback and step by step captures the behavior of the sales manager or purchasing manager.

What are some of the different types of kickback schemes?