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• Making sure the violation isn’t com- pounded or repeated.

Identity fraud and abuse red flags

One way to keep your practice opera- tions squeaky clean and in compliance with fraud and abuse laws is to develop an internal set of warning indicators. These might include:

• Significant changes in the number and/or types of claim rejections and reductions,

• Correspondence from carriers and in- surers challenging the medical neces- sity or validity of claims,

• Illogical patterns or unusual changes in coding patterns or usage, and

• High volumes of unusual charge or payment adjustment transactions.

If any of these warning indicators become apparent, the practice should follow up with an internal assessment and take corrective action, if necessary, as outlined in the practice’s compliance plan. This means both:

• Setting things right. In the case of overpayments, for example, prompt identification and repayment to the affected payer, or in the case of a po- tential criminal violation, referral or disclosure to an appropriate govern- ment authority or law enforcement agency.

Physicians can access the U.S. Health

and Human Services Office of Inspector General’s Practitioner Self-Disclosure Protocol online at authorities/docs/selfdisclosure.pdf. Avoiding fraud and abuse and know- ing how to respond if a government au- dit flags your practice for an investiga- tion are serious matters. OIG publishes an annual work plan containing activi- ties the agency will review. To access this year’s work plan, visit https://oig.hhs .gov/reports-and-publications/archives/ workplan/2013/Work-Plan-2013.pdf. For more information on compliance

program guidance for individual and small group physician practices, visit physician.pdf.

ing pay-for-delay practices illegal in the United States. The brief in Federal Trade Commis-

sion v. Watson Pharmaceuticals, Inc. et al opposes pharmaceutical industry ex- clusionary agreements, or pay-for-delay practices, that involve brand-name drug manufacturers paying competing drug manufacturers to keep cheaper generics off the market. Access the brief online at www issues/2013-01-29-amicus-brief-ftc-vs- watson-pharmaceuticals.pdf. In the brief, AMA and other groups

urged the high court to overturn an 11th Circuit Court ruling upholding exclusion payment agreements. AMA noted its concern that pay-for-delay agreements extend patent monopolies excessively, artificially inflate health care costs, and obstruct physicians’ ability to treat their patients with needed medications. “The AMA believes that pay-for-delay

Groups seek to overturn pay-for-delay drug agreements

The American Medical Association joined with AARP and other organiza- tions in filing a friend-of-the court brief in the U.S. Supreme Court seeking to remove barriers to affordable generic medications. Last November, AMA ad- opted policy that would support mak-

agreements undermine the balance be- tween spurring innovation through the patent system and fostering competi- tion through the development of generic drugs,” said AMA President Jeremy A. Lazarus, MD. “Pay-for-delay must stop to ensure the most cost-effective treatment options are available to patients.” Pay-for-delay agreements between

drugmakers are on the rise. A report issued in January by the Federal Trade Commission identified 40 potential pay- for-delay deals, the highest of any year since the agency began collecting data in 2003. To read the report, visit www.ftc .gov/os/2013/01/130117mmareport.pdf. Other organizations that joined in signing onto the AARP-led brief include the National Legislative Association on Prescription Drug Prices and the U.S. Public Interest Research Group. n

Crystal Zuzek is an associate editor of Texas Medicine. You can reach her by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email at


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