Two new healthcare reform measures have recently been passed, including the Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reconciliation Act of 2010.  Together these hefty volumes- more than 900 pages in all- constitute quite a weighty legislative tome, but buried inside all of this text are several very weighty anti-fraud and theft measure, proving once again that governments aim is hitting  healthcare hard from a fraud and abuse perspective.

Section 6402(h)(1) is one of the most worrisome sections of this legislation because it affords the right of the Secretary to suspend all Medicare/Medicaid payments to any provider against whom a “credible allegation” has been made.  Of course what is considered “credible” is not defined in any of the pages reformIn essence any organization, or individual who is a healthcare provider, upon facing any type of “credible allegation” will no longer be able to receive any type of Medicaid/Medicare reimbursement…..a reimbursement that accounts for more than 58% of an average practices revenue stream.  Allegations need not be for fraud, if a provider fails to notify the state of a change of address, fails to “fully cooperate” during a site visit, or is accused of incorrect coding and/or billing all payments may be suspended effective immediately.  This means that any physician or organization could face indefinite suspension pending an investigation….not a conviction….an investigation….and could be forced out of business due to the lost revenue.

Another potentially dicey section is 6402(f)(2) which was written as a preventative measure against kickbacks, and improper referrals.  Unfortunately the new legislation can hold a person who “had no knowledge of this law, no intent to commit a violation of this law, and was not directly involved in the violation” responsible

We strongly recommend that all organizations have a compliance program in place, and that this healthcare compliance program continually reviews the latest laws and regulations pertaining to the industry.