Health Care Counsel

Arent Fox's health care law blog offers news, analysis, and insights for the health care industry.

Health Care Counsel

Fraud & Abuse Compliance

Arent Fox is an industry leader on the numerous complex legal requirements that apply to relationships among providers, suppliers and other companies doing business in the health care industry, as well as their relationships with physicians. Our lawyers are nationally recognized for their expertise and experience counseling clients on the Anti-Kickback Statute, the Stark Law, the False Claims Act, the laws relating to beneficiary inducement prohibitions, civil monetary penalties, exclusion, fee splitting, the corporate practice of medicine, and their State counterparts. In addition, Arent Fox attorneys have deep experience with the myriad Medicare and Medicaid reimbursement issues that often form the basis for fraud and abuse enforcement.

We have advised hospitals and health systems (including specialty hospitals such as LTACHs, children’s hospitals and AMCs), nursing homes, hospices, home care agencies, medical device and pharmaceutical manufacturers, ambulatory surgery centers, clinical laboratories, therapy companies, and a broad range of other health care providers and suppliers, as well as clinical researchers and health care practitioners.

Our team is at the forefront of health care compliance and includes professionals with decades of experience counseling clients on complex regulatory matters, including former HHS and OIG counsel, a Medicaid Inspector General, certified professional coders and clinicians as well as nationally recognized experts in the fraud and abuse laws and Medicare requirements.

Our practice includes advising clients on the development and implementation of strategies to minimize exposure under the fraud and abuse laws; working proactively with management, employees and Board members to develop effective compliance programs, policies and training tailored to the specific regulatory environment. We help conduct internal audits to evaluate specific regulatory issues as well as overall compliance program effectiveness. Arent Fox attorneys frequently assist clients in determining when a compliance failure creates overpayment liability, assessing the scope of potential liability and making disclosures to the appropriate government entity.

Another key part of our practice involves guiding clients through government-initiated audits, limiting the audit’s scope where possible, and preempting unnecessary disputes and litigation. Where our clients have been unable to avoid litigation, we have won and successfully settled many major cases.

We have experience defending matters related to:

  • Billing and coding errors (or alleged fraud) related to Medicare and Medicaid payment and coverage requirements (on issues ranging from inpatient admission/observation status to the DRG payment window, appropriate level of supervision, use of modifiers, and services furnished by excluded providers)
  • Government medical reviews, audits and investigations initiated by agencies such as the Department of Justice (DOJ), the Office of Inspector General of the Department of Health and Human Services (OIG), the Medicare Administrative Contractors (MACs), the Recovery Audit Contractors (RACs), the Zone Program Integrity Contractors (ZPICs), and Medicaid Fraud Control Units (MFCUs)
  • Challenging overpayment determinations (especially by RACs) through administrative appeals
  • Clinical research fraud
  • Challenging billing privilege suspension, revocation or program enrollment termination.

Our attorneys understand the collateral consequences that can result from fraud and abuse investigations, and we help clients avoid or defend against exclusion, suspension, or debarment.


In A Must Read, New OIG Guidance Provides Practical Ways to Evaluate Compliance Program Effectiveness

The Department of Health and Human Services recently issued an important new compliance guide, called Measuring Compliance Program Effectiveness: A Resource Guide. The Guide is a combined effort of HHS’s Office of Inspector General and the Health Care Compliance Association and provides guidance on evaluating compliance program effectiveness based on the input of 40 compliance professionals and OIG staff.


Health Fraud Rule Withdrawal May Hurt Enforcement Efforts

Partner Linda Baumann was recently quoted in the Bloomberg BNA article, “Health Fraud Rule Withdrawal May Hurt Enforcement Efforts,” appearing in both the Health Care Daily Report and the Medicare Report. The article discusses how fraud enforcement efforts in the health care industry may be hindered by the Trump Administration’s delay of a program integrity final rule that would have strengthened the government’s ability to suspend or revoke provider enrollment in Medicare and Medicaid.


OIG 2017 Work Plan Lists New Enforcement Priorities

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently published its Work Plan for fiscal year 2017 (2017 Work Plan), which furnishes key guidance to providers and suppliers (collectively referred to here as “providers”) and others doing business in the health care industry on the agency’s enforcement priorities for the upcoming year.

Ensuring Compliance With CMS 60-Day Overpayment Rule

* The following alert was originally published in Health Law360. To read it on the Health Law360 website, click here


Don't Have a Heart Attack...but Enforcement Scrutiny Increasing Against Some Cardiac Care Providers

* The following alert was originally published in California Healthcare News (CHN). To read it on the CHN website, click here.


CMS Proposes New Requirements for Stark Self-Disclosures

On May 6, 2016, CMS published in the Federal Register a request for comments on proposed revisions to the information to be collected pursuant to the CMS Voluntary Self-Referral (Stark) Disclosure Protocol (SRDP). The proposed revisions introduce a new SRDP submission form and update the requirements of the SRDP to reflect recent regulations that require providers to self-disclose overpayments going back up to six years, when appropriate.


Office of Inspector General Evaluates the Enhanced Enrollment Screening of Medicare Providers

In March 2012, the Centers for Medicare & Medicaid Services (CMS) enhanced its Medicare enrollment screening for new and existing enrollees to the Medicare program.  Providers not meeting CMS’s enhanced enrollment screening  risk denial, revocation, or deactivation of Medicare billing privileges.


Providers Take Note: What the New Stark Regulations Mean to You

The Centers for Medicare & Medicaid Services recently issued final regulations implementing the Stark Law as part of the Physician Fee Schedule for 2016. While many of the changes are intended to make it easier for providers to comply with the Stark Law’s complex requirements, that should not engender a false sense of security.


DOJ Attorneys Disclose Health Care Enforcement Trends for 2016

Federal prosecutors appearing at the American Conference Institute’s 16th Annual Forum on Fraud and Abuse in the Sales and Marketing of Medical Devices earlier this month outlined recent enforcement trends that should catch the attention of the health care industry. Companies that ignore the warnings and lessons stemming from these public comments do so at their own peril, especially with regard to the False Claims Act.


Linda Baumann Named to Law360 Health Editorial Advisory Board

Health Care partner Linda Baumann was recently selected as a member of the Law360 Health editorial advisory board. The purpose of the editorial advisory board is to gain insight from experts on developments in the field and how best to shape future coverage. Linda Baumann heads the Washington, DC office of the Arent Fox Health Care group. She counsels clients nationwide on compliance, False Claims Act cases, internal investigations, self-disclosures, CIAs as well as the Stark Law and Anti-Kickback Statute.


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Arent Fox LLP, founded in 1942, is internationally recognized in core practice areas where business and government intersect. With more than 350 lawyers, the firm provides strategic legal counsel and multidisciplinary solutions to clients that range from Fortune 500 corporations to trade associations. The firm has offices in Los Angeles, New York, San Francisco, and Washington, DC.