FINANCE
Physician-Syndicated “ MSO Models ”
mercial insurance coverage only , do , in fact , have a non-obvious supplemental Medicare or Tricare plans , thus invoking original OIG jurisdiction .
------- MAIL & WIRE FRAUD
By sending physicians questionable distribution checks via mail , the MSO may commit mail fraud , a federal felony under 18 U . S . C . § 1341 . By submitting erroneous bills electronically , the MSO may commit wire fraud , a federal felony under 18 U . S . C . § 1343 .
------- CLIA & DEA & MEDICARE LICENSE
The physician has a DEA license and therefore subjects himself / herself to federal rules ; the affiliated pharmacy or toxicology laboratory has a Medicare or Tricare number and a CLIA license issued by the Centers for Medicare and Medicaid .
------- INTERSTATE COMMERCE
Not all participating physicians may be from the issuing state and the MSO or the pharmacy / laboratory may engage in interstate commerce , which creates original jurisdiction for federal authorities . The same rationale of interstate commerce applies to commercial insurance carriers that are located out of state .
“ The risk is real . In fact , several branches of the Department of Justice are responding to federal carve-outs by prosecuting healthcare entrepreneurs and companies under federal statutes for DEA , SEC , and kickback violations .
Oberheiden | Elliott | Byrd | Sauter
THIS IS WHAT PHYSICIANS SHOULD DO
We believe that the physician ’ s exposure in PSMSOs can be substantial . The monetary volume generated by PSMSOs and affiliated ancillary services make PSMSOs attractive targets for FBI and OIG agents . Deviations from legal standards as grave as noticed in some of the reviewed PSMSOs could trigger civil or criminal prosecutions or medical board actions against PSMSO participants . Depending on the PSMSO structure , executives and physicians could be subject to False Claims Act , Stark Law , and kickback prosecutions .
Healthcare Fraud is investigated by the Office of Inspector General ( OIG ), the Department for Health and Human Services ( HHS ), the Department of Justice ( DOJ ), and the Federal Bureau of Investigation ( FBI ). To minimize their exposure , physicians should request the following documentation and compliance certifications .
PHYSICIANS SHOULD REQUEST THE FOLLOWING DOCUMENTS :
1 . Documentation of an independent fair market value analysis that was issued prior to the PPM release and that concluded that the service fee between the MSO and affiliated pharmacy , lab , implant company etc . reflects fair market value .
2 . Detailed documentation of each of the MSO ’ s past and ongoing efforts to meet all of the eight elements of the safe harbor it relies upon .
3 . Documentation that proves that the syndicated MSO has been registered with the SEC at the time of its formation .
33 TODAY ’ S PRACTICE : CHANGING THE BUSINESS OF MEDICINE