Diagnostic Imaging/Testing

Diagnostic Imaging/TestingNelson Hardiman counsels and assists diagnostic imaging and testing facilities across a wide range of business, regulatory, and strategic challenges. The diagnostic imaging and testing industry will continue to undergo significant reform as facilities work to control cost, integrate delivery systems and adapt to changes resulting from implementation of the Affordable Care Act (“ACA”). The ACA, in addition to providing government regulators with an additional $350 million over 10 years to boost anti-fraud efforts, increases federal sentencing guidelines for health care fraud by 20-50% for crimes with more than $1 million in losses, and subjects facilities and providers who pose a higher risk of fraud or abuse to enhanced screening, including license checks and site visits. In addition, the Centers for Medicare and Medicaid Services (“CMS”) now uses predictive modeling technology to target highly suspect behaviors of facilities. Enforcement actions in the diagnostic imaging and testing space from 2015 arose from a wide variety of activities, including improper billing (billing for services not provided, unbundling of codes, double billing), improper relationships with referring physicians (employing or contracting with referring physicians for medical directorships, equipment or facility lease arrangements below fair market value) and failure to comply with coverage or payment rules (lack of required supervision).

The government will continue to investigate and prosecute fraud and abuse within the diagnostic imaging and testing arena, and providers should expect the government to double down on its enforcement activities after 2015’s banner year for collection of over-payment and penalties from individuals and entities participating in federal and state health care programs. The challenge for diagnostic imaging and testing facilities is to maintain compliance across a number of coverage, billing and coding rules and regulations.

Nelson Hardiman is at the forefront of issues affecting the diagnostic imaging and testing industry and provides diagnostic imaging and testing facilities with legal representation across a wide variety of business regulatory and compliance issues, including:

  • Business Transactions
    • Formation of corporations and corporate governance
    • Formation of management companies
    • Accountable care organizations (ACO’s)
    • Purchase and sale agreements
    • Management service agreements
    • Managed care contracts
  • Regulatory Defense
    • Medical Board investigations
    • DEA audits and investigations
    • Reimbursement audits and investigations by private and governmental payors
  • Compliance
    • Corporate practice of medicine
    • Physician supervision
    • Medicare and Medi-Cal credentialing
    • Medicare Anti-Markup rule
    • Stark and Anti-Kickback Statute compliance
    • HIPAA and state patient data privacy and security requirements
    • Audit risk assessment
    • Informed consent and patient agreements
  • Litigation
    • Licensure defense and appeals
    • Medicare and Medi-Cal appeals
    • Payor and reimbursement disputes
    • Overpayment appeals
    • False Claims Act / Qui tam whistle-blower litigation defense
    • Business and employment litigation
    • Medicare and Medi-Cal exclusions and suspensions
    • Lawsuit defense