Governance and Fraud in Health Care Organizations - Legal and Ethical Responsibilities
Name of the Laws
The Anti-Kickback Statute (42 USC § 1320a-7b(b)) prohibits offering, paying, soliciting and
receiving anything of value to induce, reward referrals, or generate Federal health care program
The intent to violate this statute has to be proven and all referrals are included.
Penalties for violating this statute include criminal and civil punishment.
Criminal punishment under sections 1128B(b) and 1128B(f) of the Act (42 U.S.C.
1320a–7b(b) involves fines up to $25,000 per violation, up to a 5 year prison term per violation.
Civil punishment includes: False Claims Act liability, civil monetary penalties and program
exclusion, potential $50,000 CMP
per violation, civil assessment of up to three times amount of
kickback. Exceptions include voluntary safe harbors. This Statute applied to all Federal Health
Care Programs (Department of Health and Human Services, 2013).
The Stark Law (42 USC § 1395nn) 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. This law prohibits the
designated health services entity from submitting claims to Medicare for those services resulting
from a prohibited referral. This law involves only a physician’s referrals violation. The intent of
violating this statute does not have to be proven, it is a strict liability. Intent is required for civil
monetary penalties for knowing violations. Only civil penalties are imposed for violating this
law. Penalties for violations include: overpayment or refund obligation, False Claims Act
Remuneration includes kickbacks, bribes, rebates made in cash or in kind. The payment of remuneration intended to induce or reward the
purchasing, leasing, or ordering of, any god, facility, service, or item reimbursable by any Federal health care program (Department of Health and
Human Services, 2013).
the civil monetary penalty