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MEDICARE AND MEDICAID FRAUD AND ABUSE is a single volume, softback, comprehensive and practical guide to federal fraud and abuse law issues. Over her entire career, Alice G. Gosfield has regularly advised clients throughout the country on avoiding fraud and abuse liability, whether from false claims, Stark and anti-kickback liabilities, civil money penalties and increasingly from fraud and abuse based on quality related issues. This book has been updated to reflect the most recent Stark regulations, OIG Fraud Alerts and Bulletins, and offers real life scenarios in application of complex regulatory provisions. Marc Raspanti and David Laigaie, who have written the chapter on investigations, are recognized nationally as premier white collar defense lawyers who also have brought some of the highest profile whistleblower health care fraud cases including SmithKline and now Merck-Medco. Their guidance with respect to investigations is invaluable. The book includes six chapters, heavily footnoted to permit readers to go further on any topic, including statutes, regulations and caselaw. Chapters include An Introduction to Medicare and Medicaid Fraud and Abuse focused
around industry sectors and enforcers; The Stark Statute and Regulations in context with reimbursement rules as well; Administrative Penalties and Exclusions which are often overlooked and misunderstood; False Claims: Criminal, Civil and Qui Tam Actions including their bases and theories Investigations as explained by Marc Raspanti and David Laigaie The book is available from WestGroup. Now in its sixteenth edition, the HEALTH LAW HANDBOOK has become a well regarded annual resource edited by Alice G. Gosfield. This book brings you the insights and knowledge of 19 national health law experts on some of the most important and cutting edge issues in health law today in 14 separate and entirely new articles organized around four significant themes driving health law challenges today: (1) quality; (2) fraud and abuse; (3) regulation in specified industry segments; and (4) communication issues with legal liabilities. This year’s fourteen articles are grouped as follows: Quality Issues including clinical integration under antitrust written by one of the authors of the FTC’s position on the subject, the role of quality in defining post-merger markets, my article on pay for performance and other quality based contracting issues, and handling disruptive physicians under the ADA; Fraud and Abuse including the annual comprehensive and incisive update by Sanford V. Teplitzky and Craig Holden, an update on EMTALA, the new focus on DME, home health and hospice providers Regulatory mandates regarding office based clinical trials, corporate governance for not for profits after Sarbanes-Oxley and pharmacy benefit managers in the regulatory cross-airs Communication issues including proactive strategies to manage poor clinical outcomes in hospitals, risk management under the HIPAA security regulations, liabilities in e-health initiatives and the legal ethics of lawyer to lawyer communications in health care. The book is available from WestGroup. |
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| PHYSICIAN AND MEDICAL PRACTICE HIPAA PRIVACY COMPLIANCE PROTOCOL Modeled on our Fraud and Abuse Compliance Protocol, this 60 pp document breaks down HIPAA Privacy Compliance into understandable steps. With a Glossary, List of Resources, and Key Questions for each of the 8 Steps to Compliance, a medical practice can come to grips with creating a customized, manageable, realistic response to the mandate to have a compliance program in place. Compliance is not a one size fits all proposition, nor is this document a book of forms, although the government’s Business Associate model contract is included. This document helps practices develop their own program without paying exorbitant fees to external consultants who don’t know what you do as well as you know it. Failure to conform to the regulations can lead to fines as well as criminal penalties. This document is available for $75 billed to clients, and $125 prepaid to non-clients. PHYSICIAN AND MEDICAL PRACTICE FRAUD AND ABUSE COMPLIANCE PROTOCOL We do not write compliance plans since we believe that the best compliance plan is one in which the client is fully invested in terms of time and intellectual commitment. We have, however, developed a compliance protocol entitled, "Physician and Medical Practice Compliance Protocol." As with much in compliance, this 42 page document will be dynamic and updated over time. It is available for $75 for clients and $125 for non-clients prepaid. A GUIDE TO KEY LEGAL ISSUES IN MANAGED CARE QUALITY Alice Gosfield’s enlightening book, A Guide to Key Legal Issues in Managed
Care Quality is now available directly from Alice G. Gosfield and Associates, P.C.
Originally sold for $145, we can make this 253 page book, originally published by Faulkner
and Gray available to you for $95 plus $5 shipping and handling ($100 total prepaid). This book is for non-lawyers. Written in a breezy, informative style, it examines the single most challenging problem in the new era -- quality in managed care. The impact of the law on this effort is central to the critical insights and elucidations offered. In nine chapters, this book addresses fundamental legal principles which pertain to relationships in managed care, caselaw on liability, state regulation of managed care quality, accreditation, typical provider contract provisions which affect quality, federal controls on managed care quality, and issues in performance measurement and data dissemination. Finally, the book outlines the basic questions all of the health care players must address in the day-to-day world as well as in public policy as we grapple with this most vital problem for the American people. The table of contents includes the following: Chapter 1 The Quality of Health Care: Is It Strained? A discussion of basic principles of quality and value purchasing juxtaposed against managed care techniques. The entities involved in providing managed care and new theories of managed care quality are presented. How the law influences quality is described. Chapter 2 Who’s Responsible?: Liability in Managed Care Caselaw Potentially the most contentious issue in health care today, this chapter looks at the caselaw on ERISA through 1995 which has led to today's patients' rights debate. Anybody who cares about patients' rights needs to understand the matters here. Chapter 3 What Big Brother is Watching: Federal Controls on Managed Care
Quality Bob Roth, a veteran health law practitioner in Washington, D.C. wrote this chapter dealing with the role of the federal government generally and the quality control systems which were in place under federal law prior to Medicare+Choice. Chapter 4 Carrots and Sticks: The Federal Fraud and Abuse Laws and Quality It is not well understood that there has long been a concern for quality under federal law. This chapter looks at new theories of quality and false claims, and the government’s authority over exclusions, intermediate sanctions and civil money penalties as they relate to managed care. Anti-kickback laws and the Stark statute are also addressed as they were in effect as of 1995. Chapter 5 The Wheat From the Chaff: Accreditation and Regulation Accreditation entities have multiplied and the way they approach accreditation in managed care varies. This chapter looks at the link between accreditation and regulation and the activities of multiple accrediting bodies including NCQA, JCAHO, URAC and the now defunct TMQC (The Medical Quality Commission). Chapter 6 The Little Red Hen Syndrome: States and "Anti-Managed
Care" Laws Bob Roth looks at the ERISA laws and how states launched into solving the problem of managed care reform before the federal government ever picked up the issue. The phenomena he identified continued throughout the country and remain in place. Chapter 7 What’s the Deal?: Contractual Terms Aimed at Quality Control and Risk Management Managed care contracts with physicians and providers include many provisions that go well beyond the payment system or compensation rates. This chapter elucidates those provisions in managed care contracts which are intended to motivate provider behavior with regard to quality. Chapter 8 Numbers, Numbers, Who’s Got the Numbers?: Law and the Quantification of Quality The advent of performance measurement and report cards found its basic iterations in the managed care world. The role of clinical practice guidelines and the implications of HEDIS date are considered along with beginning issues associated with data protection and confidentiality. Chapter 9 Back to the Future: Millennial Speculations This chapter draws together the themes in the book and speculates on the implications of developing trends in late 1995. That which was predicted has come true and one review compared this chapter with the prophecies of Nostradamus! |
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