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Referral Restrictions Changes Under PPACA: Mildred L. Johnson, J.D., CPC, CCEP Aubry Moore

The document discusses changes to anti-kickback restrictions under the Patient Protection and Affordable Care Act (PPACA). Key points include that PPACA relaxes the specific intent requirement for violations of the Anti-Kickback Statute, expands what constitutes a false claim under the False Claims Act, and amends the definition of remuneration to exclude payments that promote access to care and pose low risk of harm. Additionally, PPACA requires all Medicare providers and Medicaid providers to implement mandatory compliance plans.

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Aubry L Moore
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101 views15 pages

Referral Restrictions Changes Under PPACA: Mildred L. Johnson, J.D., CPC, CCEP Aubry Moore

The document discusses changes to anti-kickback restrictions under the Patient Protection and Affordable Care Act (PPACA). Key points include that PPACA relaxes the specific intent requirement for violations of the Anti-Kickback Statute, expands what constitutes a false claim under the False Claims Act, and amends the definition of remuneration to exclude payments that promote access to care and pose low risk of harm. Additionally, PPACA requires all Medicare providers and Medicaid providers to implement mandatory compliance plans.

Uploaded by

Aubry L Moore
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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REFERRAL RESTRICTIONS

Changes under PPACA

Presented by:
Mildred L. Johnson, J.D., CPC, CCEP
Aubry Moore October 18, 2010
Agenda
Anti-Kickback Restrictions

1 Overview & Brief History of Anti-Kickback Laws

7
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Anti-Kickback - Language
• (1) (a) whoever knowingly and willfully solicits or receives any remuneration (including any
kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or in kind--

• (A) in return for referring an individual to a person for the furnishing or arranging for the
furnishing of any item or service for which payment may be made in whole or in part under
a Federal health care program, or
 
• (B) in return for purchasing, leasing, ordering, or arranging for or recommending
purchasing, leasing, or ordering any good, facility, service, or item for which payment may
be made in whole or in part under a Federal health care program,
 
shall be guilty of a felony and upon conviction thereof, shall be fined not more than
$25,000 or imprisoned for not more than five years, or both.
 
• (b) With respect to violations of this section, a person need not have actual knowledge of
this section or specific intent to commit a violation of this section
Anti-Kickback - The What
• Prohibits the offer, solicitation, payment or
receipt of anything of value in exchange for:
1) Referring an individual for items or services paid
for by a federal health care program
2) Purchasing, leasing, ordering or arranging for any
good, facility, service or item paid under a federal
health care program
3) Recommending the purchase, lease, or order of
any good, facility, service or item paid under a
federal health care program
Historical Perspective
• The intent of the anti-kickback law is to
eliminate payment for referrals of
Medicare/Medicaid patients or business that is
paid for by those programs.
• Any payment for referral, including profit
distributions, made to a physician or other
healthcare provider is suspect.
• Care facilities and their suppliers are not
exempt
General Environment
• National debate over health care reform
– Reform passed March 21, 2010
– Reconciliation bill passed days later

• Increased enforcement actions and recovery


– Whistleblower encouragement
Health Care Reform
• Patient Protection and Affordable Care Act
(“PPACA”)
– Signed into law March 23, 2010 (HR 3590)
– Sidecar Bill (HR 4872)
– Changes to Anti-Kickback
PPACA
• Access to Care
– Provisions to encourage training of primary care
physicians and general surgeons
– Sustains and improves access to care in rural areas
– Extends selected provisions for long-term care
hospitals
– Additional requirements for charitable hospitals
PPACA
• Mandatory Compliance Plan
– All suppliers and providers enrolled in Medicare,
and all providers enrolled in Medicaid, required to
implement a compliance plan that contains core
elements laid out by the Secretary of HHS
PPACA
• Fraud and Abuse
– Anti-Kickback Statute (AKS), Section 1128B(b) of
Social Security Act (42 U.S.C. r1320a-7b(b))
• Specific intent requirement relaxed
• A violation of AKS now constitutes a false or fraudulent
claim under FCA
• Definition of remuneration is amended for the
beneficiary inducement provisions to exclude any
remuneration that promotes access to care and poses a
low risk of harm to patients and federal healthcare
programs.
PPACA
• Fundamentally transforms America’s health
care system
– Impacts providers, insurers, employers,
individuals, states and localities
Responses and Prevention
• Get involved in new arrangements
• Establish or update compliance programs and
policies
• Address possible new FCA exposure
• Understand risk of whistleblowers
• Reevaluate HIPAA privacy and security plans,
and amend business associate contracts
• Scrutinize physician relationships

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