b'CODING Update ComplianceLEGAL NUTRITIONUpdateANJC NewsANJC Leadership ANJC News!The RICO Act: LEGAL EASE NUTRITION From Gangsters to DoctorsBy Jeffrey RandolphANJC Legal CounselREHAB Update Passed in 1970, the Racketeer Influenced and Corrupt Orga- ANJC Scholarshipssymptoms do not resolve.The MRI center had solicited nizations Act (RICO) is a federal law designed to combatthe chiropractors referrals and pays cash for each patient organized crime in the United States.It allows prosecutionthat the chiropractor refers for testing.The MRI results are and civil penalties for racketeering activity performed as partpositive and the patient is referred for EMG/NCV testing to a of an ongoing criminal enterprise.Though initially targetedneurologist that rents space in the chiropractors office.The at organized crime, creative attorneys have found new waysrent paid by the neurologist varies based upon the numberCHIRO Assistto utilize the RICO Act against non-criminals, specificallyof patients that the chiropractor refers to them.EMG/NCV healthcare providers.This article will review the history of theLEGAL Q&Atesting shows radiculopathy and the patient is referred to RICO Act and how it is now being applied against healthcarea pain management doctor for an epidural who also rents Executive Directors Update space from the chiropractor.The epidural is performed providers in the 21st century, decades after its initial enact-ment to fight organized crime. in an ambulatory surgical center in which both the pain Now in its fourth decade of existence, RICO was passedmanagement doctor and the treating chiropractor have an2020 ANJC AWARDSby the U.S. Congress to pursue Mafia kingpins and not justownership interest, receive dividend payments, and also are low-level mafia soldiers.Prior to RICO, it was difficult toemployees of as directors of their respective specialties.prosecute the higher-ups in organized crime who remainedThe above scenario is all that is needed for an insurance layers of underlings who committed the actual crimes.RICOLegislative Updateinsulated from the commission of actual criminal acts bycarriers attorney to plead a case under the civil RICO statute and most likely survive a motion to dismiss.There INSURANCE Update INSURANCE Update is an enterprise of healthcare providers who are referring changed this by permitting prosecution of all those involved in the planning, ordering, and commission of crimes bypatients to each other, some receiving direct cash kickbacks, defining them as a criminal enterprise. while others get kickbacks as hidden rent that fluctuatesTECHNIQUE UpdateThe RICO statute allowed prosecutors to gather togetherbased upon patient numbers.The Ambulatory Surgical crimes going back many years into a single case, establishingCenter is implicated in paying what may be excessive a pattern of criminal activity of many crimes over manydividends or directorship salaries that may be essentially years as a RICO enterprise.To establish a RICO claim, theno-show jobs and a hidden kickback to providers that refer prosecutor must prove that a criminal enterprise engagedthem cases.There is a pattern of illegal activity which may MedicareQ&AMedicare Updatehave gone on for a number of years establishing a business in certain illegal predicate acts, such as mail or wire fraud,pattern and practice of improper activity.As precertificationOUR HEALTHand that a business pattern and practice of illegal activityand appeals were done by fax and insurance claims was the basis of the enterprise.A successful claimant undersubmitted by mail, there are the required predicate illegal a civil RICO case can recover triple damages plus attorneysacts of wire fraud and/or mail fraud.fees and costs, making the civil RICO statute a formidable weapon in litigation.Some high-profile examples of civilThe healthcare providers involved in the above scenario face RICO cases include lawsuits brought against BP for the Gulfa long and expensive course of litigation to trial or, in the of Mexico oil rig disaster and Bernard Madoff for his financialalternative, an expensive settlement.A typical settlement Ponzi scheme. under a civil RICO case is tripartite:i) a waiver of all pending So how does this apply to healthcare providers, you mayclaims outstanding with the insurance company that filed ask?In the recent years, auto insurance companies in bothsuit; ii) repayment of claims that the carrier paid them over New York and New Jersey have filed suit against healthcarethe past six years; and iii) possibly forward-looking billing providers and their referral network alleging that non-med- restrictions such as an agreement not to bill the insurer for a ically necessary care, referrals, and procedures constituteperiod of time or an agreement not to bill for more than a set a criminal enterprise and seek triple the amount that theynumber of visits.paid the providers for the past six years (the RICO statuteIn conclusion, though 1970s RICO targeted murderers and of limitations) plus attorneys fees and costs.As you canloan sharks, civil RICO in the 21st century has expanded to imagine, the damage figures that they are seeking can betarget healthcare providers with claims for triple damages, staggering. attorneys fees, and an irreparably harmed reputation.It is A hypothetical example of a claim against healthcarebetter to avoid any of the practices that could form the basis providers under Civil RICO is as follows:A patient getsof a civil RICO suit than to make ill-gotten gains and have to injured in an automobile accident and seeks care from apay it back times three.chiropractic physician.The chiropractor treats the patient for a month and refers the patient for an MRI when their 6 I Summer 2021 www.anjc.info'