Tag Archives: physician referral

Former Tuomey CEO Settles with DOJ for $1 Million

By Donna S. Clark and Banee Pachuca on Posted in Uncategorized
The U.S. Department of Justice (DOJ) recently reached a $1 million settlement with Ralph J. Cox III, the former CEO for Tuomey Health System, Inc. (Tuomey), in connection with his involvement in the notable Stark Law case. After protracted litigation, Tuomey agreed to pay $72.4 million in October 2015 to settle allegations that the system had violated the … Continue Reading

The Deeper Dive: Senate Finance Committee Examining Modernization of the Stark Law

By Darby C. Allen and Donna S. Clark on Posted in Uncategorized
The Committee’s interest in the Stark Law and receptiveness to feedback from industry leaders may indicate that significant changes to the law are in the pipeline. As the healthcare industry moves from a fee-for-service (FFS) reimbursement system for physicians to a value-based payment system, industry insiders are questioning whether the federal physician self-referral law and … Continue Reading

Insurer Actions Cut the Heart Out of Out-of-Network Providers

Photo of Robert M. WolinBy Robert M. Wolin on Posted in Uncategorized
Aetna Life Insurance Company recently won a $37 million verdict against a group of Northern California surgical centers, Bay Area Surgical Management, LLC and its affiliates (collectively, Bay Area), for an alleged out-of-network overbilling scheme and kickbacks to referring physicians. This lawsuit is simply one more effort in a larger trend by insurers to make it more … Continue Reading

CMS Finalizes Revisions to Stark to Ease Burden on Providers, Refines “Incident to” Requirements

Photo of Kristen McDermott WoodrumBy Kristen McDermott Woodrum, Darby C. Allen and Donna S. Clark on Posted in Uncategorized
In its calendar year 2016 Physician Fee Schedule Final Rule published in the Federal Register on November 16, 2015 (Final Rule), the Centers for Medicare and Medicaid Services (CMS) finalized amendments to the federal physician self-referral (Stark) regulations proposed in the Physician Fee Schedule proposed rule released in July. Among the significant provisions contained in the Final Rule are … Continue Reading

Texas Hospital Strikes Back at Aetna

By B. Scott McBride, Darby C. Allen and John W. Petrelli on Posted in Uncategorized
On February 23, 2015, Aetna filed suit in Texas federal court against Robert A. Behar, M.D. and North Cypress Medical Center (North Cypress), alleging that Dr. Behar, the CEO of North Cypress, offered impermissible ownership stakes in the 139-bed community hospital in exchange for patient referrals and designed an out-of-network business strategy that gave rise … Continue Reading

Proposed Rule Aims to Refine Stark Regulations and Clarify “Incident To”

Photo of Kristen McDermott WoodrumBy Kristen McDermott Woodrum and Darby C. Allen on Posted in Uncategorized
On July 15, 2015, the Centers for Medicare and Medicaid Services (CMS) published the calendar year (CY) 2016 Physician Fee Schedule Proposed Rule. In addition to updating several traditional Part B payment policies, the proposed rule contains significant changes to the physician self-referral regulations (Stark regulations) and the Medicare “incident to” coverage rule. The comment … Continue Reading

Tuomey Judgment Upheld in Novel Stark Law and False Claims Act Case

By Donna S. Clark and Darby C. Allen on Posted in Uncategorized
The U.S. Court of Appeals for the Fourth Circuit recently upheld the judgment against Tuomey Healthcare System, Inc. (Tuomey), in a qui tam False Claims Act case predicated on Stark Law violations. The district court in the case had previously upheld a jury verdict finding that Tuomey, a community hospital in South Carolina, violated the … Continue Reading

Seventh Circuit Upholds Physician’s Conviction for Violation of the Anti-kickback Law Based on Expansive Definition of “Referral”

By Nita Garg on Posted in Uncategorized
On February 10, 2015, the U.S. Court of Appeals for the Seventh Circuit upheld the conviction of Dr. Kamal Patel for violation of the anti-kickback law, reinforcing a broad definition of “referring” under the statute (U.S. v. Patel, Seventh Circuit Court of Appeals, No. 14-2607, Feb. 10, 2015). Dr. Patel, a physician who often prescribed … Continue Reading

Aetna Out of Patience With Hospital’s Alleged Out-of-Network Billing Scheme

By B. Scott McBride, Darby C. Allen and John W. Petrelli on Posted in Uncategorized
Aetna Life Insurance Company (Aetna) is going on the offensive against a Northwest Houston hospital with an out-of-network strategy. On February 23, 2015, Aetna filed suit in Texas federal court against Robert A. Behar, M.D. and North Cypress Medical Center (North Cypress), alleging that Dr. Behar, the CEO of North Cypress, offered impermissible ownership stakes … Continue Reading

Government Sues Hospital for Birthing Mama’s Babies

Photo of Robert M. WolinBy Robert M. Wolin on Posted in Uncategorized
The Clinica de la Mama case could well serve as an instruction manual of what not to do to stay out of the government’s crosshairs. In this case, several hospitals entered into contracts for Clinica de la Mama to provide “services” including translation, translation management, consulting, eligibility determination, marketing, birth certificate, educational, community outreach and … Continue Reading

Stark Law Update: All Children’s Settles False Claims Act Allegations

By Donna S. Clark and Darby C. Allen on Posted in Uncategorized
All Children’s Health System (ACHS) will pay the federal government and state of Florida $7 million to settle allegations that it violated the federal and Florida False Claims Act statutes by submitting claims to Medicaid that were illegal under the Stark Law. The whistleblower in the case was the Director of Operations of Pediatric Physician … Continue Reading

Halifax Reportedly Settles Landmark Stark Case

By Donna S. Clark and Darby C. Allen on Posted in Uncategorized
According to minutes filed in the U.S. District Court for the Middle District of Florida, Halifax Hospital Medical Center (Halifax) and the U.S. Department of Justice (DOJ) have reached a settlement in the pending False Claims Act case in which Halifax is accused of entering into financial relationships with medical oncologists and neurosurgeons in violation … Continue Reading

OIG and CMS Extend Expiration Date for EHR Donations

By Donna S. Clark and Darby C. Allen on Posted in Uncategorized
As the final days of 2013 passed and the sunset of the Stark Law exception and anti-kickback law safe harbor for electronic health record (EHR) donations loomed nearer, the U.S. Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) and Office of Inspector General (OIG) issued last-minute final regulations to … Continue Reading

Federal Judge Dismisses All Anti-Kickback Claims in Halifax Hospital Medical Center Case

By Donna S. Clark and Darby C. Allen on Posted in Uncategorized
On January 8, 2014, the U.S. district judge in the Halifax Hospital Medical Center (Hospital) case pending in the Middle District of Florida granted the Hospital’s motion to dismiss all of the relator’s anti-kickback law claims. This False Claims Act case is partially predicated on alleged violations of the Stark Law and the anti-kickback law … Continue Reading
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