Chapter 5 — Further Reading

Nothing on this page, or in this chapter, is legal advice. These are the primary sources; consult counsel for anything concrete.

Tier 1 — Verified canonical sources

False Claims Act, 31 U.S.C. §§ 3729–3733. Read § 3729(a) for the prohibited conduct, § 3729(b)(1) for the definition of "knowingly," and § 3730 for the qui tam and anti-retaliation provisions. It is short, it is readable without legal training, and the definition at § 3729(b)(1) is the most important paragraph in this chapter.

Anti-Kickback Statute, 42 U.S.C. § 1320a-7b(b), and the safe harbor regulations at 42 C.F.R. § 1001.952. The safe harbors are technical and all-or-nothing; read one in full to see what "every element" means in practice.

Physician self-referral law (Stark), 42 U.S.C. § 1395nn, and the implementing regulations at 42 C.F.R. §§ 411.350–411.389. Note the structure: a broad prohibition followed by exceptions, each with enumerated requirements. That structure is why Stark compliance is a documentation discipline.

Civil Monetary Penalties Law, 42 U.S.C. § 1320a-7a, and 42 C.F.R. Part 1003. Penalty amounts are adjusted for inflation and must be looked up currently.

Exclusion authorities, 42 U.S.C. § 1320a-7, and the OIG's List of Excluded Individuals and Entities (LEIE) at exclusions.oig.hhs.gov — free and searchable. Also the OIG's special advisory bulletin on the effect of exclusion, which explains the scope that §5.5 summarizes: items and services furnished, ordered, or prescribed, and employment in any capacity.

Affordable Care Act overpayment provision, 42 U.S.C. § 1320a-7k(d), and the implementing regulations on reporting and returning overpayments — including the treatment of "identification" and reasonable diligence. The sixty-day rule.

OIG Compliance Program Guidance. The OIG has published guidance for individual and small group physician practices, for hospitals, for third-party medical billing companies, and — more recently — consolidated General Compliance Program Guidance. The seven elements come from here. Read the one for your setting. The physician practice guidance in particular is written for small organizations and is unusually practical.

OIG Self-Disclosure Protocol. The route Case Study 2 uses. Its requirements, and the treatment of self-disclosure as a mitigating factor, are set out by the OIG directly.

HIPAA: the Privacy Rule at 45 C.F.R. Part 164, Subpart E (including § 164.502(b) and § 164.514(d) on minimum necessary, and § 164.506 on treatment, payment, and health care operations); the Security Rule at Subpart C; the Breach Notification Rule at Subpart D; and the Transactions and Code Sets standards at 45 C.F.R. Part 162 — which is where the mandate of ICD-10-CM, CPT, and HCPCS actually lives.

HHS Office for Civil Rights guidance, enforcement highlights, and published resolution agreements. The resolution agreements are the most useful reading here: they describe, factually, what went wrong in real organizations.

Department of Justice annual False Claims Act statistics. Published yearly, including the health care share and the qui tam share. Look up the current year rather than citing any figure from a book.

Tier 2 — Attributed, specifics unverified

AAPC and AHIMA codes of ethics and their standards of ethical coding. The professional obligations in §5.10 are drawn from these; read the one your credential is under. Both are free.

OIG Work Plan, updated monthly. What is currently being examined. Chapter 37 returns to it; for this chapter it is worth skimming once to see how specific it is.

Health care fraud enforcement reporting and analysis from law firm client alerts, professional associations, and trade press. Useful for patterns and for early notice of enforcement themes; verify anything specific against the underlying settlement documents or court filings, which are usually public.

Commentary on qui tam policy, both supportive and critical. Case Study 1 summarizes both positions without resolving them; the underlying literature is substantial and worth reading if you find the question interesting, which you should.

Compliance program design resources from healthcare compliance professional organizations, including sample policies, risk assessment methodologies, and audit workplan templates scaled to practice size.

Tier 3 — Illustrative and constructed

Figure 5.1 and Account 31-2245 — the shoulder arthroscopy claim, the 42-claim review, the \$612.40 average overpayment, and the \$25,720.80 demand. Constructed. The coding relationships it describes (an add-on code, a bundled debridement, and a distinct-procedural-service modifier applied by macro) are real and are worked in detail in Chapter 21 §21.9.

Case Study 2 in its entirety — the twelve-physician group, the 610 claims, the \$74.20 average overpayment, the \$45,262.00 repayment, and the \$82,662 total. A composite built from documented compliance guidance and the overpayment rule, labeled as constructed within the case study.

The §5.10 counterfactual note — the stripped two-line assessment that would not support modifier 25. Constructed, as a deliberate contrast with the real Figure 4.2.

If you read only three things after this chapter

1. 31 U.S.C. § 3729(b)(1), the definition of "knowingly." Three sentences. It is the single most consequential paragraph for anyone in this profession, and almost nobody in this profession has read it.
2. The OIG Compliance Program Guidance for your setting. Free, plain English, and it tells you what an organization is expected to have — which is also a description of what a good employer looks like.
3. Your credentialing body's code of ethics. Ten minutes. You will be measured against it, and it is short enough to actually hold in mind.