Healthcare Practice Management: Compliance, Revenue, and Legal Defense

Ownership of a medical practice in most states is restricted to licensed physicians under the corporate practice of medicine doctrine, and violations can result in the invalidation of all contracts between the practice and its non-physician investors, the voiding of insurance contracts, and mandatory recoupment by Medicare and Medicaid of reimbursements paid to a provider that was not lawfully constituted, meaning that every dollar earned since formation becomes recoverable by the government. The healthcare compliance and regulatory and healthcare laws practice areas provide the CPOM analysis and healthcare practice management ownership structure compliance needed.

Management services organizations allow non-physician investors to participate in the economic value of a medical practice without directly owning the clinical entity, and healthcare practice management counsel designing an MSO structure must ensure that the management services agreement gives the MSO commercially reasonable authority over business functions while preserving the physician entity's exclusive authority over all clinical decisions, because an agreement giving the lay MSO control over clinical staff will be scrutinized as a disguised lay ownership arrangement. The business formation and healthcare practice areas provide the MSO agreement structure review and healthcare practice management corporate law compliance needed.

Stark Law at 42 U.S.C. §1395nn prohibits a physician from referring Medicare or Medicaid patients for designated health services to any entity with which the physician or an immediate family member has a financial relationship unless the arrangement fits within one of the statutory exceptions, and because the Stark Law is a strict liability statute the government only needs to prove that the financial relationship existed and the referral was made while no exception applied, making healthcare practice management pre-implementation review essential. The medicare billing fraud and healthcare fraud practice areas provide the Stark Law exception analysis and healthcare practice management referral compliance needed.

Unlike the Stark Law's strict liability framework, the Anti-Kickback Statute at 42 U.S.C. §1320a-7b(b) requires proof of intent but its definition of remuneration encompasses free or below-market office space, equipment loans, excessive compensation for medical directorships, and speaker fees for programs that primarily serve marketing purposes, and healthcare practice management must evaluate every such arrangement against the applicable safe harbors. The healthcare compliance and regulatory and regulatory compliance practice areas provide the Anti-Kickback safe harbor analysis and healthcare practice management compensation arrangement review needed.

Submitting a claim for a service at a higher complexity level than the documentation supports, or submitting separate claims for services that should be billed together, are both False Claims Act violations that expose the practice to treble damages plus civil monetary penalties of up to $27,894 per false claim under 2024 penalty adjustments, and healthcare practice management counsel must audit both the coding practices and the documentation practices that underlie them. The medicare billing fraud and healthcare fraud practice areas provide the False Claims Act exposure analysis and healthcare practice management billing compliance program needed.

Protected health information held by a covered entity is subject to the HIPAA Breach Notification Rule at 45 C.F.R. §164.400, which requires notification to affected individuals within 60 days of discovery, and a breach affecting 500 or more patients in a single state must be reported to the Secretary of HHS and to prominent media outlets simultaneously, and healthcare practice management must maintain a legally reviewed HIPAA breach response plan because the failure to notify within the statutory deadline is itself a separate violation. The digital health laws and regulations and data privacy practice areas provide the HIPAA breach response protocol and healthcare practice management patient data security program needed.

Non-compete clauses in physician employment agreements must navigate state law rules that vary from complete prohibition in states like California, Colorado, and Minnesota to graduated enforceability standards based on geographic scope and duration in states that permit restrictions, and healthcare practice management counsel drafting these provisions must recognize that an unenforceable non-compete can potentially invalidate the entire compensation arrangement if it was the consideration supporting an above-market salary package. The healthcare and healthcare laws practice areas provide the physician non-compete enforceability analysis and healthcare practice management employment contract review needed.

Effective healthcare practice management counsel addresses every legal risk that a medical practice faces from the moment of formation through each stage of growth.

The healthcare compliance and regulatory and healthcare practice areas provide the healthcare practice management integrated legal strategy, multi-statute compliance design, and complete medical practice representation needed.