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Fraud alert: recognizing relationships that may trigger fraud and abuse concerns for physicians

February 05, 2015


The laws regarding fraud, abuse and anti-kickback violations can be complicated and difficult for physicians to navigate. However, it is increasingly important that physicians be aware of relevant prohibitions to avoid being implicated in a potentially fraudulent scheme.


The California Medical Association (CMA) has received reports that some clinical laboratories, especially those testing for cardiovascular markers, are offering physicians cash incentives for blood draws of Medicare patients. Accepting such incentives could put physicians afoul of laws governing fraud and abuse.


Anti-kickback laws prohibit physicians from offering or receiving anything of value in exchange for referral of patients. Although a number of safe-harbor provisions exist to limit the breadth of this prohibition, it is strictly enforced.


Additionally, self-referral laws prohibit physicians from referring their patients for specified goods or services to entities in which the physician or a member of the physician's immediate family has a financial interest. Again, although exceptions do exist, the law presumes there is an ethical dilemma whenever a physician refers a patient to an entity in which he or she has a financial interest.


CMA offers informational materials to help physicians understand these complex laws and the potential consequences of partnerships or agreements they enter into. Physicians with questions about specific arrangements should contact an attorney or their professional liability carrier to navigate the complexities of the anti-kickback and referral prohibitions applicable to their unique situation.


To learn more about fraud and abuse laws, see the chapter titled "Fraud and Abuse: Referral Issues" in CMA's online health law library. The health law library is free to members inCMA's health law library . Nonmembers can purchase documents for $2 per page.


Contact: CMA Legal Information Line, (800) 786-4262 or legalinfo@cmadocs.org.

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