Doing What is Right: The Importance of Knowing and Acting on Published Guidance

Doing what’s right begins with knowing what’s right—and when it comes to compliance, knowledge isn’t optional. The Office of Inspector General (OIG) and other regulatory bodies provide clear guidance on laws and regulations to promote accountability and prevent misconduct. Ignorance of these rules is not an excuse for non-compliance. The OIG’s stance is clear: if guidance is published, you’re responsible for knowing it, understanding it, and applying it.

The OIG’s message boils down to a critical principle: It’s about the responsibility to be knowledgeable. In fields like healthcare, finance, and government contracting, where regulations are complex and violations carry severe consequences, staying informed is not just good practice—it’s essential. This includes understanding critical frameworks like the False Claims Act, the Anti-Kickback Statute, Stark Law, Civil Monetary Penalties Law, and other compliance standards.

Why “Knowing” Matters in Key Compliance Areas

1. False Claims Act (FCA): A Heavyweight of Accountability

The False Claims Act prohibits knowingly submitting false or fraudulent claims for payment to the government. “Knowingly” here is key—it includes actual knowledge, reckless disregard, or deliberate ignorance of the truth. If you fail to familiarize yourself with billing rules, coding guidelines, or other published requirements, you risk being held liable under the FCA, even if you didn’t intentionally commit fraud.

Examples:

• Billing Medicare for services that were not medically necessary or not provided.
• Submitting claims that violate other laws, such as the Stark Law or Anti-Kickback Statute.

The FCA also carries steep penalties, including treble damages and fines per false claim, making ignorance a costly mistake.

2. Anti-Kickback Statute (AKS): Know the Rules to Avoid Improper Incentives

The Anti-Kickback Statute prohibits offering, paying, soliciting, or receiving remuneration in exchange for referrals for services covered by federal healthcare programs. This includes waiving copays or deductibles in a way that incentivizes unnecessary services or violates program requirements.

The OIG publishes extensive guidance on what constitutes permissible conduct under the AKS. Failure to read and implement this guidance risks substantial fines and exclusion from federal healthcare programs. Waiving copays improperly, for example, may violate the AKS and result in liability under the FCA.

3. Stark Law: Self-Referral Requires Caution

The Stark Law bans physician self-referrals for certain designated health services covered by Medicare and Medicaid, unless a specific exception applies. Knowing these exceptions, published extensively in OIG and CMS materials, is critical. Failing to familiarize yourself with these rules—or worse, ignoring them—can result in civil penalties and Medicare program exclusions.

For instance, if a hospital compensates a referring physician above fair market value or without documentation of services rendered, it could trigger a Stark Law violation.

4. Civil Monetary Penalties Law (CMP): Penalties for Waiving Copays and More

The CMP Law prohibits specific conduct, including presenting false claims, violating the Anti-Kickback Statute, or improperly waiving copays and deductibles for Medicare and Medicaid beneficiaries. Some providers mistakenly believe they’re helping patients by waiving copays—but doing so without meeting the strict exceptions published in guidance can lead to penalties.

Published Guidance: A Responsibility to Be Knowledgeable

The OIG doesn’t just enforce these laws—it provides detailed guidance to help individuals and organizations understand their responsibilities. This guidance is often clear, specific, and publicly accessible. However, failure to engage with this information is considered willful ignorance. Turning a blind eye to regulations doesn’t shield you from liability.

Examples of Published Guidance You Should Know:

• Compliance Program Guidance for Healthcare Providers
• Advisory Opinions and Fraud Alerts from the OIG
• CMS Rules on Billing and Documentation Standards
• FAQs and Updates on Stark Law and AKS Exceptions

Your Responsibility to Act

Being knowledgeable about compliance isn’t just about protecting yourself from penalties; it’s about fostering trust and integrity. Here’s how you can ensure you meet your responsibility:

1. Stay Informed Regularly review OIG advisories, CMS updates, and other regulatory publications relevant to your field. Sign up for newsletters and alerts to stay updated on changes.
2. Implement What You Know Knowledge isn’t enough if it doesn’t translate into action. Update your policies, billing practices, and procedures to reflect current guidance.
3. Train Your Team Provide education and training to ensure your staff understands the rules. Everyone involved in compliance must be on the same page.
4. Audit and Monitor Regularly review your practices to ensure they align with the law. Conduct internal and?external?audits, monitored claims submissions, and investigated potential issues promptly.
5. Seek Clarification When in doubt, seek guidance. Submit questions to the OIG or consult with compliance experts to avoid misunderstandings.

The Bottom Line

Doing what’s right means embracing the responsibility to be knowledgeable—and taking action based on that knowledge. Whether it’s the False Claims Act, Stark Law, the Anti-Kickback Statute, or the CMP Law, you are accountable for understanding the rules that govern your work. When the OIG publishes guidance, it’s your job to take it in, apply it, and ensure compliance across your organization.

The stakes are high, and ignorance is not an excuse. Compliance isn’t just about avoiding penalties; it’s about demonstrating integrity, protecting your organization, and ultimately serving the public trust. Make no mistake: knowing is your responsibility, and doing what’s right starts with being informed.