Fraud and abuse will continue to be a challenge

Hospital risk managers need to think about how the Affordable Care Act (ACA) is changing the laws governing fraud and abuse, says Kathy Tayon, JD, shareholder with the law firm of Fowler White Boggs in Fort Lauderdale, FL.

In 2010, the ACA gave the government even more tools to prevent healthcare fraud, including additional screening and enrollment requirements, data sharing across government, overpayment recovery efforts, and oversight of private insurance abuses.

“Risk managers should keep in mind that ideas that maybe seem good from a marketing or business perspective — giving gifts to patients for referrals or a physician investing in a healthcare business to which he or she refers, — may be illegal under federal or state healthcare anti-kickback laws or self-referral laws,” Tayon says. “Risk managers need to educate both clinical and non-clinical staff about the anti-kickback and self-referral laws to ensure that any marketing programs are compliant.”

The clinical staff needs to accurately and completely document the delivery and medical necessity of services provided, and those preparing the bills must understand the billing rules, she says. Policies and procedures must be in place to help ensure that all needed criteria to bill a service are met.

The ACA requires healthcare providers to create compliance and ethics programs that contain certain core elements as a condition of enrollment in the federal healthcare programs. Failure to do so could have catastrophic consequences when the organization cannot participate, she notes.

“Risk managers should develop written policies and procedures that promote and help ensure compliance with healthcare laws in developing and operating the organization,” she says. “The policies and procedures should be part of the organization’s everyday operations, and the organization should know and comply with them.”


  • Kathy Tayon, JD, Shareholder, Fowler White Boggs, Fort Lauderdale, FL. Telephone: (954) 703-3903.