Fraud & Abuse and Compliance
Congress has created a sweeping arsenal of criminal, civil and administrative weapons designed to deter and punish health care fraud and abuse. The U.S. Departments of Justice and Health and Human Services, in turn, have made fraud and abuse a top law enforcement priority. Pillsbury is well versed in the large and growing body of fraud and abuse laws, including those statutes and regulations concerning the payment of kickbacks, physician self-referral, reassignment of claims, payment suspension, overpayment recoupment and program exclusion. Our lawyers, several of whom have been assistant U.S. attorneys or worked for the Department of Justice and the office of the Inspector General, are intimately familiar with and closely monitor the law enforcement landscape and are uniquely positioned to provide health care clients with legal advice in four areas:
- Structuring business arrangements to comply with federal and state anti-kickback and physician self-referral laws.
- Operating on a daily basis in accordance with the ever-changing and increasingly complex web of laws and regulations governing billing and reimbursement, patient referral, marketing, managed care, and fraud and abuse issues.
- Developing compliance programs that are consistent both with Office of Inspector General guidelines and the size, resources, patient mix and risk areas of the client.
- Conducting internal investigations and litigation risk assessments and -where an action has been brought by a federal or state government agency or a private "whistleblower" - defending clients in criminal, civil and administrative litigation.
- Negotiating and implementing settlements with federal and state agencies when investigations, enforcement actions, and criminal charges have been brought against our clients.
