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Health Care Fraud and Abuse: Practical Perspectives, Third Edition, outlines in detail the existing fraud and abuse laws, regulations, case law, and other government activity, and offers attorneys the practical perspectives and guidance they need to protect their clients. This incomparable treatise offers seasoned counsel, as well as those new to health care law, assistance in structuring acceptable business arrangements, avoiding statutory and regulatory pitfalls, defending clients against government investigations and litigation, implementing effective corporate compliance programs, and more.
The Third Edition has been reorganized to include a separate, comprehensive chapter on the Anti-Kickback Statute, full of practical guidance. The Third Edition also includes material on: two key new OIG documents issued in 2013: the OIG Provider Self-Disclosure Protocol and the OIG Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs (both documents superseding prior guidance on these topics); multiple new settlements and other government enforcement actions and initiatives throughout the health care industry; recent Stark Law developments, including the Tuomey case, one of the few Stark Law cases to go to trial; key developments in the False Claims Act prosecution of off-label marketing cases, (e.g., the Caronia case); increasing enforcement in the Part D arena, including CMS’s concern with preferred networks and other Part D-related issues, as evidenced in multiple OIG audits, Work Plan items, CMPs and False Claims Act cases; and developments indicating potential individual liability, particularly for directors and officers of health care organizations, in areas such as anti-trust and the Foreign Corrupt Practices Act.
The 2018 Cumulative Supplement contains:
Notable settlements with pharmaceutical companies, hospitals and health systems, long-term care companies, pharmacies and pharmacy benefit managers, medical device companies, and individuals, particularly directors and administrators of healthcare providers and suppliers
Discussion on the likelihood of increased enforcement efforts in the future
Detailed indications of an effective compliance program from the OIG’s model compliance programs and a DOJ memorandum
Practical tips for private equity firms after the DOJ’s intervention in a False Claims Act case naming a private equity firm as a defendant, as well as other decisions discussing falsity, implied false certification, and materiality
Updates on the substantial enforcement efforts related to combatting the opioid crisis
OIG Work Plan topics, by category, for the last five fiscal years
Coverage of the Shared Savings Program offering different participation tracks allowing ACOs to assume various levels of risk
Gainsharing arrangement OIG guidance—the first to address gainsharing since the passage of MACRA
Activities of private enforcers such as qui tam relators, private insurance companies, and derivative actions by shareholders
Summary of Contents
Chapter 1. Introduction
Chapter 2. Federal Physician Self-Referral Restrictions
Chapter 3. The False Claims Act
Chapter 4. Practical Considerations for Defending Cases
Chapter 5. Hospital and Physician Relationships
Chapter 6. Care Fraud and Abuse
Chapter 7. Corporate Compliance Programs
Chapter 8. Potential Liabilities for Directors and Officers of Health Care Organizations
Chapter 9. The Anti-Kickback Statute: A Practical History
Chapter 10. Controlling Fraud, Waste, and Abuse in the Medicare Part D Program
Chapter 11. Clinical Trials
Appendices • Table of Cases • Index
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