American Alliance Health Services (AAHS), and all of its subsidiaries and Advocates, are committed to compliance with all applicable federal and state laws and regulations. We expect all AAHS employees, physicians and other providers, officers, directors, independent contractors and agents to support all of our compliance efforts. To that end, AAHS promotes a culture of compliance and ethical conduct and as part of that culture, this philosophy sets the standards for all that we do. Although this compliance summary cannot address all that must be done to achieve total compliance; we believe that together with our policies and procedures, this summary provides guidelines for how we should conduct ourselves in all that we do.
All members of the AAHS workforce, including employees, physicians and other providers, contractors, agents, care center staff, officers and directors, must conduct themselves at all times, in accordance with the following policies, applicable laws and regulations, and the highest standards of business and professional ethics.
The Medicare and Medicaid Patient Protection Act of 1987 is referred to as the Anti-kickback Statute. The statute provides criminal penalties for certain acts impacting Medicare and Medicaid reimbursable services. Particularly, the statute prohibits the offer or receipt of certain remuneration in return for referrals for or recommending the purchase of supplies and services reimbursable under government healthcare programs. Advocates CANNOT offer to give money back to individuals or physicians.
The Medicare anti-kickback statute prohibits (1) the willful solicitation or receipt of remuneration in return for referrals of Medicare patients for any service for which payment may be made in whole or in part under Medicare or a State health care program, and (2) the offer or payment of remuneration to induce such referrals. Persons who violate the statute shall be guilty of a felony and upon conviction, shall be fined not more than $25,000 or imprisoned for not more than five years, or both. Thus, the Act explicitly prohibits any remuneration knowingly and willfully offered or paid to induce, or solicited or received in return for, Medicare or Medicaid patient referrals.
Most providers are aware that paying kickbacks for referrals is a felony under the Anti-kickback Statute (AKS), 42 U.S. Code § 1320a–7b (b)(1)1. You can get into very big financial trouble, and lose your license. Unlike Stark law, 42 U.S.C. 1395nn., which only applies to physician referrals, the AKS applies to remuneration paid to anyone for arranging in whole, or in part, the furnishing of services or items covered by a federal healthcare program. This means the AKS is broad enough to cover payments to a sales force which is paid on commission. The actual wording of the statute reads:
Whoever knowingly and willfully solicits or receives any remuneration (including any kickback, bribe or rebate) directly or indirectly, overtly or covertly, in cash or in kind—in return for referring an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under a Federal healthcare program, or in return for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under a Federal healthcare program, shall be guilty of a felony and upon conviction thereof, shall be fined not more than $25,000 or imprisoned for not more than five years, or both.
Stark Law is a set of United States federal laws that prohibit physician self-referral, specifically a referral by a physician of a Medicare or Medicaid patient to an entity providing designated health services (“DHS”) if the physician (or an immediate family member) has a financial relationship with that entity. (read entire article). Advocates CANNOT offer to pay a physician for conducting any of the tests. A physician CANNOT become an Advocate unless, they are retired and no longer practicing medicine. A physician CANNOT be paid to offer the test to their patients.
The Federal Ethics in Patient Referrals Act (commonly referred to as the “Stark Law”) prohibits referrals for certain “designated health services” to entities with which a physician (or a physician’s immediate family member) has financial relationships, including either an ownership interest or a compensation arrangement, unless the financial relationship falls within a specific statutory or regulatory exception. The Stark Law mandates the nature of relationships that AAHS can enter into with physicians. Exceptions to the Stark Law allow many common arrangements (e.g., lease arrangements, employment agreements, personal services arrangements, etc.) despite the Stark Law’s general prohibition on self-referrals. Failure of a physician financial relationship to fit within an applicable exception means that such physician cannot make referrals to the entity with the financial relationship regardless of the medical necessity of such service. Any payment received by the entity furnishing designated health services is treated as an overpayment for Medicare reimbursement purposes. Neither AAHS nor the Physicians may engage in any conduct that violates the Stark Law and Physicians shall minimize the risk of any inadvertent violation of the Stark Law. AAHS may seek assurances from any vendor having a financial relationship with a Physician or Care Center, that the vendor has no compensation relationships that violate the Stark Law. AAHS may periodically engage outside counsel and experts to monitor it’s continuing compliance with the Stark Law.
Fraud By Deception Law
To protect consumers, the law is very specific about what AAHS Advocates may or may not do. For example:
Advocates CANNOT market through unsolicited contact, including:
- Telemarketing calls, including voice mail messages, emails or texts
- Door-to-door solicitations, including leaflets or flyers at your home or car
- Approaching Medicare beneficiaries in common areas, like parking lots, hallways, lobbies, and sidewalks.
Advocates CAN speak with a client on the phone only if the client calls you first.
Advocates CAN go to client’s home only if you have previously been invited by client to do so
Advocates CANNOT dress up as a medical provider of any type unless they are a licensed medical provider.
Safe Harbor Laws
AHHS has taken the financial obligations to make sure all employees are statutory employees who are paid a salary with tax withholdings and who are also offered benefits. Section 530 of the Internal Revenue Code (IRC) includes a safe harbor provision relating to the classification of workers as independent contractors. Under this provision, a company is not liable for employment taxes if it can demonstrate that a reasonable basis for treating workers as independent contractors exists, and if the employer can meet three reasonable basis standards.
The Affordable Care Act includes a safe harbor for affordability for employee health care coverage. If it’s not affordable, you can’t be held to a responsibility to pay for it.
Another safe harbor provision is the IRS Special Accounting Rule that allows employers to treat non-cash fringe benefits provided in November or December as being provided in the following year.
The domestic production activities deduction for U.S. manufacturing businesses provides a safe harbor provision that allows businesses to take this deduction if at least 20 percent of the total costs are the result of direct labor and overhead costs from US-based operations
AAHS WILL ALWAYS REQUIRE REGULATORY COMPLIANCE WITH FEDERAL & STATE AUTHORITIES, EKRA AND CMS.
To assist AAHS in accomplishing this goal, we require our Advocates possess a professional licence in the medical or insurance industry or have comparable experience in these fields. All Advocates are protected under a Certificate of Liability Insurance Policy, through AAHS.
Knowing and maintaining compliant standards are ongoing requirements for all Advocates. Advocates and corporate employees are required to be HIPAA certified and pass a comprehensive course covering the various rules and regulations that pertain to our business and follow them compliantly at all times. Periodic visual and recorded trainings are conducted, to further enhance the importance of staying compliant.
AAHS Advocates are required to study and understand the State and Federal guidelines that regulate the health care industry. Advocates must conduct themselves in the most compliant manner at all times. Being professional is paramount to our success as a compliant company and even more important to our customers who look to us for education and advice.
AAHS ADVOCATES ARE STATUTORY W-2 EMPLOYEES
AAHS is committed to satisfying the requirements of CMS and Medicare by classifying Advocates as statutory employees. Statutory employees are allowed the benefit of direct deductions against income, enjoyed by Schedule C filers without the self-employment tax burden such filers face. However, the ability to file as a statutory employee applies only to the categories of employees listed in Sec. 3121(d)(3). To be classified as a statutory employee, the worker must exhibit more of the traits of an independent contractor than of a common law employee. Generally, this means that the employee has control over how work is accomplished with a minimum amount of input by the employer. Courts will often look to the intent of the parties to determine statutory employee status. A critical component of intent is whether the employer has checked the Form W-2 box identifying a statutory employee. However, as shown in Hathaway, even when the employer fails to check the box and withholds income taxes—factors indicating common law employee status—the overall facts may be support — allowing the worker to file a Schedule C.
Code of Ethics
All members of the AAHS workforce, including AAHS advocates, employees, physicians and other providers, contractors, agents, care center staff, officers and directors of AAHS, its subsidiaries and affiliates, must conduct themselves at all times in accordance with all applicable laws and regulations and the highest standards of business and professional ethics.
Each AAHS Care Center provides patient care services consistent with high standards of quality established by the company and advising physicians. If the application of a law or regulation is unclear, Advocates should request guidance and advice from their AAHS manager. AAHS strives to maintain complete, accurate and reliable documentation to ensure that all claims for payment comply with applicable legal and contractual requirements. We recognize the importance of maintaining relationships with referral sources and hospitals and other providers to which AAHS providers refer patients directly or indirectly. All such relationships must be established and maintained based on the quality and relative costs of such services and the needs of our patients; not on any financial relationships with such referral sources. All contacts and communications between AAHS Advocates and governmental officials, whether direct or indirect, must be accurate, complete and current without any attempt to exert or benefit from undue influence. Advocates must not offer anything of value to such officials to obtain a particular result. Advocates may not provide or pay for any meal, refreshment, entertainment, travel or lodging expenses for government employees without the prior written approval of the Compliance Officer. AAHS strives to maintain accurate and reliable corporate records that disclose all payments and other transactions to which AAHS is a party; AAHS is committed to ensuring the accuracy of all filings with local, state and federal governmental agencies. AAHS’s successful operation requires the dilligence of all of our Advocates in the exercise of their responsibilities. Therefore, except as approved by AAHS’s Board of Governors, personal investments or other activities that may create a conflict of interest are prohibited, and circumstances that may give the appearance of a conflict of interest are to be avoided.
Laws and Legal Duties
AAHS is committed to complying with all applicable laws and avoid even the appearance of wrongdoing. While it is not practical to attempt to list all laws to which AAHS is subject, it is obvious that neither AAHS nor its Advocates should encourage or participate in, directly or indirectly, such activities as theft, fraud, embezzlement, bribery and false statements to the government. Advocates should not engage in any fraudulent, deceptive or corrupt conduct toward AAHS or its patients, patients’ family members, suppliers, contractors, employee representatives or anyone else with whom AAHS conducts business. Examples of prohibited activities include, without limitation, kickbacks, inflated billings and the offering, accepting or soliciting, directly or indirectly, of money, goods or services when the purpose of the action is to influence a person to act contrary to professional judgment in the interest of his own employer or principal or fiduciaries. AAHS is committed to complying with Federal statutes and state statutes prohibiting the filing of false claims for payment that carry civil penalties, including fines and civil monetary penalties. In addition to the specific laws described herein, other laws to which AAHS must pay particular attention are as follows:
HIPAA Privacy and Security: AAHS shall create and implement a privacy plan and security plan that conform with the HIPAA privacy and security standards. AAHS Health shall designate a HIPAA Privacy Officer and a HIPAA Information Security Officer (who may be the same individual) to ensure all aspects of the HIPAA privacy and security plans are implemented appropriately. All Advocates shall complete an online class and obtain an official HIPPA Certification.
Obstruction: It is a crime to willfully prevent, obstruct, mislead, delay (or to attempt to do so) the communication of records relating to a Federal health care offense to a criminal investigator.
Federal False Claims: Under the civil False Claims Act, any person who submits a false or fraudulent claim for payment to the United States Government is subject to a fine of from $5,500 to $11,000 for each claim plus three times the amount claimed. In addition, under certain circumstances, private individuals can bring “qui tam” (whistleblower) suits in the name of the United States against health care providers, and the individual shares in any recovery against the provider. False claims can arise from any of the fundamental areas of regulatory risk.
First, failure to correctly file claims for payment in a manner that constitutes either “deliberate ignorance” or “reckless disregard” of the claims accuracy could lead to liability under the False Claims Act. 29.
Second, the Patient Protection and Affordable Care Act of 2010 includes a provision that any referral made that is pursuant to an arrangement that violates the Anti-Kickback Statute is a “false claim”. Similarly, alleged violations of the Stark Law are frequently used in False Claims Act actions brought against providers.
In addition, states in which AAHS operates also have state-specific false claims acts. Each Advocate is responsible for understanding both the Federal False Claims Act and the applicable state false claims act that impacts his or her particular Care Center.