Healthicity
Share:
Recent enforcement actions highlight the ongoing need for proactive compliance oversight in credentialing, billing practices, and financial relationships with referral sources.
Below are three real-world cases that offer important reminders and action points for hospital compliance teams.
- Unnecessary Surgical Procedures and Fraudulent Inductions
Case: A Virginia medical center was indicted for alleged healthcare fraud tied to medically unnecessary surgical and obstetric procedures. The hospital allowed a surgeon—whose privileges had been revoked elsewhere for unnecessary surgeries—to perform elective deliveries, many of which occurred before 39 weeks of gestation and without medical necessity.
Compliance Takeaway: Credentialing Isn’t “One and Done.”
Hospitals must perform rigorous and continuous credentialing and privileging reviews, especially when previous disciplinary actions are known. Regular audits of scheduling, clinical documentation, and gestational age accuracy are essential to prevent both quality-of-care concerns and billing fraud.
- Billing for Services by an Unlicensed EMT
Case: A critical access hospital in Illinois self-disclosed that it had billed for services rendered by an Emergency Medical Technician who was not properly licensed, resulting in a $107,000 settlement with the OIG.
Compliance Takeaway: Verify, Then Trust.
All staff providing billable services must maintain appropriate and current licensure. Periodic internal audits and automated license verification tools can reduce risk. Even when the error is unintentional, billing for unlicensed services violates the Civil Monetary Penalties Law.
- Improper Financial Relationships in Jointly Owned Office Space
Case: An Indiana hospital agreed to pay over $768,000 to resolve allegations that it paid remuneration to physicians and practices by covering maintenance and business expenses for a jointly owned office building—potentially violating the Anti-Kickback Statute and the Physician Self-Referral Law.
Compliance Takeaway: Every Arrangement Deserves Scrutiny.
Financial relationships with referral sources, even those involving shared expenses or office space, must be structured and monitored in strict accordance with Anti-Kickback Statute and Stark Law. Hospitals should routinely review such arrangements and consider self-disclosure if potential violations arise.
Bottom Line for Compliance Teams
These enforcement actions are reminders that compliance is not static—it requires active oversight, continual verification, and timely intervention. Hospitals must foster a culture where issues are self-identified and reported, and where documentation and credentialing processes are as strong as the clinical care they support.
If you’d like to stay in-the-know on the latest compliance news and enforcement actions, sign up for our Healthcare Compliance Weekly Newsletter, featuring curated stories and insights from our team of compliance experts.
Also, would you like to download this blog post as a pdf, click the button below.
Questions or Comments?