Healthcare Billing Agreements & Regulatory Compliance
Texas Healthcare Attorneys Serving Providers Nationwide
Healthcare providers often partner with third-party contractors to handle medical billing and other administrative tasks more efficiently. These outsourced management services can also include designated health services, which provide critical support to physicians and their patients.
Ensuring that your relationships and agreements with these service providers – such as medical billing companies and other third-party contractors – are compliant with applicable state and federal healthcare laws is critical to a thriving, enduring practice.
Medical Billing Agreements and Exposure to Risks
Medical billing agreements, as well as billing practices, are closely scrutinized by regulators to ensure they do not violate healthcare fraud and abuse laws, including self-referral laws (such as the Stark Law), the Anti-Kickback Statute, and the False Claims Act.
Violating these and other regulations can subject providers to substantial penalties. Check that your agreements are in compliance during new practice set-ups, mergers and acquisitions, joint ventures, and when structuring any deals and transactions involving designated health services (DHS).
Our legal team has extensive experience counseling physicians, practices, and other healthcare entities as they structure their businesses, medical contracts, billing agreements, billing practices, and other essential components of their practice in a clear, compliant, and enforceable manner.
Healthcare entities and third-party services we routinely advise include:
- Physicians and medical groups
- Clinical laboratory services
- Physical and occupational therapy
- Radiology and imaging
- Home health services
- Radiation therapy
- Prosthetics and orthotics
- Medical equipment
- Personal and management services
- Outpatient prescription drugs / compounding pharmacies
Compliant Billing Agreements
Numerous state and federal regulations may apply to your business relationships and billing agreements, and specific requirements must be met in order for an arrangement to fall under a “safe harbor” or exception. Omission of even a single element required for an exception – even accidentally in some cases – can result in serious repercussions, just as erroneous entries or unusual patterns can lead to audits and recoupment.
While every case is fact-specific and demands a personalized assessment from experienced attorneys, there are a few essential issues involving billing agreements that can result in potential violations and adverse consequences such as audits, fraud investigations, subpoenas, civil or criminal penalties, or even breaches of contract.
Examples of unlawful billing arrangements can include:
- Alternative payment models that may factor volume or value of referrals into account (such as pay-for-performance or gainsharing)
- Untracked billing / compensation arrangements involving any form of remuneration (monetary or non-monetary)
- Poorly structured deals and agreements with other healthcare businesses
- Verbal agreements or any non-written agreement
- Not having billing agreements signed by all parties
- Not setting compensation in advance based on fair market value
- Failures to conduct business according to the written agreement
- Not ensuring agreements are commercially reasonable
- Billing agreements that are insufficient in duration (i.e. a minimum of one year)
Compliance in any practice and agreement begins with personalized evaluations and careful preparation that can ensure the facts of the situation, services, and parties involved are tailored in a manner that fits within a statutory exception.
Because our firm provides comprehensive counsel and representation to healthcare clients, we can also help address issues moving forward through the creation and implementation of compliance plans, ongoing counsel, and responsive representation when audits or investigations do arise.
Helping Clients Navigate a Complex Regulatory System
Regulatory compliance – whether it involves billing and compensation agreements, transactions, contracts, employment agreements, or other matters – is one of the most important aspects for a successful venture, and a task more easily said than done. By working with our legal team at Hendershot Cowart P.C., you can benefit from the insight and resources of a firm known for our work in this field, and for providing the comprehensive proactive and responsive legal services required of these high stakes issues.
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