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Background: Compliance is a fact of life for interventional pain physicians (IPPs). The health care industry is highly regulated by federal and state governments. IPPs must understand and comply with a broad regulatory landscape that ranges from health care fraud to the prescribing of oral narcotics. Complying with all of these laws requires a proactive approach by an IPP in both the practice and business of medicine., Objectives: This article provides: 1) a brief discussion of the health care laws that IPPs must navigate in their practices; and, 2) practical steps that IPPs can take to ensure that they comply with the relevant laws., Discussion: IPPs should familiarize themselves with the major federal and state fraud and abuse laws that apply to all interventional pain practices. IPPs should also implement effective compliance programs that include tools such as auditing, education, and employee reporting designed to uncover and correct fraud and abuse., Conclusion: Once in place, a compliance program can easily become part of a practice's culture and pay for itself many times over in problems avoided. IPPs that implement appropriate compliance programs can focus on the most important part of their practice: taking care of patients.

The deadlines are looming for compliance with the transaction and code set requirements set forth in the Health Insurance Portability and Accountability Act of 1996 (HIPAA). If your hospital filed for an extension in October 2002, you need to begin testing transactions by April 2003 and sending transactions by October 2003. But don't rely on your technology vendors to give you the ability to send compliant transactions. While vendors can provide the correct computer data format, they can't gather the correct information. If you can't send a compliant transaction, the Centers for Medicare and Medicaid Services could reject your claims, drying up a big percentage of your cash flow.

The vision of Hawaii's HIPAA Readiness Collaborative (HRC) effort is to realize the positive potential of HIPAA through a collaborative process that engages the entire healthcare delivery system. Goals include reducing the cost of healthcare through streamlining, reducing the cost of HIPAA implementation for HRC participants, and improving the interoperability between facilities through use of standard technologies.

The final rule implementing the privacy standards mandated by the Health Insurance Portability and Accountability Act (HIPAA) of 1996 imposes substantial requirements on covered entities with respect to their business associates--those parties providing certain services to, or on behalf of, the covered entities. A covered entity must develop a contract with each of its business associates that sets forth the conditions under which the business associate may use or disclose the protected health information it receives from the covered entity. The contract also must delineate the covered entity's obligations with respect to the business associate, which include ensuring individuals' access to their protected health information and taking certain steps to respond to a breach of the privacy standards by the business associate. The business associate requirements do not apply to the covered entity's workforce, disclosures to providers for treatment purposes, certain financial transactions, certain jointly administered government programs, and, provided that certain other restrictions are met, disclosures made by group health plans to plan sponsors.

The Health Insurance Portability and Accountability Act of 1996 will prove to be one of the most far-reaching health care reform laws of our generation. Virtually every sector of health care will need to reengineer its systems to protect its patient information infrastructure, and combat waste and abuse. The benefits will justify the efforts and costs if the result is a system in which patient medical information is protected, and information will begin to flow between payers and providers in a seamless, standardized and secure fashion. This article studies various strategies and approaches that management may use to maximize compliance efforts.

This article provides a general overview of the HIPAA privacy standards established by the Final Rules. It also discusses organizational approaches health care providers, more specifically hospitals and health systems, can use to "get started" with their HIPAA compliance effort. It also explores the corresponding human and financial resources that such providers will need to develop and implement the program. While the needs and approaches identified and discussed in this article may also apply to some extent to Covered Entities other than health care providers, this article does not specifically address those considerations in the context of health plans (including employer-sponsored plans), health care clearinghouses, or retail pharmacies.

In November 1999, under the mandate of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, HHS issued proposed standards to protect the privacy of electronically transmitted personal health information. With publication of the final standards due soon, healthcare organizations must prepare to implement new processes and information systems to comply with the HIPAA requirements. The privacy standards are intended to accomplish three broad objectives: define the circumstances in which protected health information may be used and disclosed, establish certain individual rights regarding protected health information, and require that administrative safeguards be adopted to ensure the privacy of protected health information. Among the required administrative safeguards are designation of a privacy officer, implementation of compliance training programs for all applicable staff, establishment of a complaint system, and implementation of appropriate sanctions for violations of privacy requirements.

The Department of Justice (DOJ) reports that after violent crime, health care fraud is the department's top priority. The number of health care fraud investigations pending at the DOJ increased from 270 cases in 1992 to more than 4,000 in 1997. The DOJ's primary weapon in prosecuting health care fraud is the federal False Claims Act (FCA) of 1863 (31 U.S.C. secs. 3729-3733). Almost unique among federal antifraud provisions, the FCA may also be used by "private prosecutors" to file lawsuits on behalf of the federal government charging organizations with submitting false claims to the government. The FCA rewards such whistle-blowers with a share of any resulting recoveries as a bounty and protects them from discharge for filing false claims lawsuits against their employers. It also requires defendants to pay the costs and attorneys fees of successful claimants. Although the private "bounty hunter" features of the FCA data back to the Civil War, these so-called qui tam claims were nearly dormant until 1986, when Congress amended the FCA to revive their use. Following the 1986 amendments, and paralleling the rapid increase in federal reimbursements for health care costs, private qui tam claims have far expanded beyond their traditional purview of defense contracts into the field of health care. By 1997, health care providers were the targets of 54 percent of the 530 private qui tam lawsuits field that year.

Complex regulations and statutes, murky guidance from government agencies, and overly zealous enforcement initiatives make the legal questions in the healthcare arena a veritable mine field. This Article examines some of the issues that arise in the healthcare legal setting, explains why compliance programs are difficult to establish, and analyzes the issues that arise when providers attempt to establish them. Finally, the authors suggest changes to the governing legal framework that would facilitate achievement of the government's goals in a more efficient and just manner.

The author analyzes the fraud and abuse track record of his agency in the past years, and discuss why that effort has had beneficial results for the healthcare industry and the federal fisc. The benefits of this enforcement effort flow directly from the specific enforcement actions, and indirectly from the response of others in the industry to the standards set forth in those actions. Mr. Thornton disputes assertions of some in the industry that the enforcement efforts are unfair, arbitrary, or draconian. Rather, they are an appropriate response to a documented problem with which the government is justifiably concerned.

This Federal Register notice seeks the input and recommendations of interested parties into the OIG's development of a compliance program guidance for the durable medical equipment (DME) industry, its providers and suppliers. Many providers and provider organizations have expressed an interest in better protecting their operations from fraud and abuse. Previously, the OIG has developed compliance program guidances for hospitals, clinical laboratories and home health agencies. In order to provide clear and meaningful guidance to those segments of the health care industry involved in the supply and distribution of DME, we are soliciting comments, recommendations and other suggestions from concerned parties and organizations on how best to develop compliance program guidance and reduce fraud and abuse within the DME industry.