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Healthcare Compliance Resources and FAQ
What is the False Claims Act?
The Federal False Claims Act, as amended by the FERA, establishes liability for, among other things:
- knowingly presenting, or causing to be presented, a false or fraudulent claim for payment or approval (removing the requirement that the claim be presented to an officer or employee of the Government);
- knowingly making, using, or causing to be made or used, a false record or statement material to a false or fraudulent claim;
- conspiring to commit a violation of the Federal False Claims Act; and
- knowingly making, using, or causing to be made or used, a false record or statement material to an obligation to pay or transmit money or property to the Government, or knowingly concealing or knowingly and improperly avoiding or decreasing an obligation to pay or transmit money or property to the Government.
What are the Anti-Kick Back Laws?
What are the Stark Laws?
- Prohibits a physician from referring Medicare patients for designated health services to an entity with which the physician (or immediate family member) has a financial relationship, unless an exception applies
- Prohibits the designated health services entity from submitting claims to Medicare for those services resulting from a prohibited referral
Physician Financial Transparency Reports: CMS Sunshine Act/Open Payments?
Open Payments is a federal program, required by the Affordable Care Act, that collects information about the payments drug and device companies make to physicians and teaching hospitals for things like travel, research, gifts, speaking fees, and meals. It also includes ownership interests that physicians or their immediate family members have in these companies. This data is then made available to the public each year on this website. Learn more about Open Payments.
What is the List of Excluded Individuals/Entities (LEIE)?
OIG’s List of Excluded Individuals/Entities (LEIE) provides information to the health care industry, patients and the public regarding individuals and entities currently excluded from participation in Medicare, Medicaid and all other Federal health care programs. Individuals and entities who have been reinstated are removed from the LEIE.
I have a question about billing for clinical trials or other clinical research. To whom to I talk to at Rutgers University?
Contact Ms. Cathy Florek, Senior Compliance Officer, Research, at email@example.com.
What compliance training am I required to take? How is it different from Human Subjects Training and Ethics/Code of Conduct training?
Compliance training requirements are based off job roles.
A person showed up at my desk and stated they are here from an outside organization to perform an audit, what should I do?
Ask the person for their ID. Show them to a quiet room, and let them know someone will be with them shortly. Call your manager and contact the local Compliance Officer
Someone from a Medicare contractor review vendor walked in and said they wanted to talk to one of my doctors about his documentation. Should I let that person see the doctor?
No. Call your manager, the Compliance Officer and the Office of General Counsel so that they may talk to the representative to ascertain the purpose of the visit.
What should a Provider or Department do if a letter is received from CMS, or any other government entity, requesting copies of medical records for a review or audit?
It is important to promptly and accurately act upon correspondence from governmental entities. If a Provider or Department employee receives this type of correspondence, it should be presented promptly to the Department Manager for reporting and forwarding your unit’s compliance officer.
Examples of government entities include:
- CMS (Centers for Medicare and Medicaid Services)
- RAC (Medicare Recovery Audit Contractor)
- Novitas (the Medicare Administrative Contractor or MAC)
- New Jersey Medicaid (NJ Dept of Human Services)