The Scrutiny of Medical Providers

By: Thomas M. Gallo, P.A., J.D.

It has long been held that the first critical step in engaging in, and winning, any contest is to recognize who your potential opponents are. For every physician and physician assistant (“PA”) in the country, there can be no question, clinicians are under greater scrutiny than ever,  and in order to prevail, physicians and PA’s first need to recognize, and understand, who their potential opponents are.

It is important to note at the outset that the following organizations have a vital role in society and in medicine. They are primarily designed to protect people, including patients, and us as individuals. These organizations are staffed by caring and professional people, most of whom would never abuse their power. These organizations have worked with the professionals and the leadership of the medical societies toward many improvements and have made tremendous progress as a result of this partnering. However, when their scrutiny turns on any one of us as an individual, the feelings generated are far from warm and fuzzy. Likewise, the results of an investigation can be devastating. It is from this perspective that we proceed.

So, who are these potential opponents? Who holds the power? Does anyone stand to gain from wielding such power? Unfortunately, as illustrated by the diagram below, the answer is not only yes for physicians and PA’s, but the list is growing. 

Yet, who are these anonymous acronyms? By what right, under what authority, do they hold the power over physicians and PA’s? In basic terms, they are:

BOM – Board of Medicine – known by differing names in each state – holds the power, to regulate and discipline physicians and PA’s under their license to practice medicine. New York utilizes the Office of Professional Medical Conduct (“OPMC”) in this capacity.

·    DEA – Drug Enforcement Agency – regulates and disciplines physicians and PA’s under their registration to prescribe medications (

·   AG/FCA – Attorney General / False Claims Act – investigates and prosecutes allegations of fraud under the legal authority granted by either state or federal authorities (

CMS – Centers for Medicare Services – the federal government entity that controls all aspects of Medicare and / or Medicaid services (

·   OIG/FBI – Office of the Inspector General / Federal Bureau of Investigation – designated to protect all programs under the Department of Health and Human Services through a nationwide network of audits, inspection and investigations (

HMO’s – Health Maintenance Organizations – hold the authority to credential and/or terminate clinicians who provide reimbursement for services provided to member patients.

FTC – Federal Trade Commission – investigates and prosecutes allegations of anti-trust violations – including those related to the delivery of health care services (

·         HIPAA – Health Insurance Portability and Accountability Act – through the Office of Civil Rights investigates and prosecutes privacy violations (www.cms.hhs/ocr/).

·       CLIA – Clinical Laboratory Improvement Act – regulates all laboratory services provided throughout the United States. (

·   EMTALA – Emergency Medical Treatment and Active Labor Act – imposes obligations upon healthcare facilities and clinicians to provide emergency services regardless of an ability to pay (

·   OSHA – Occupational Safety and Health Administration – sets and en-forces standards for workplace safety, including blood borne pathogens and infection control (
·         MEC – Medical Executive Committees – through hospital by-laws – credentials and disciplines clinicians’ medical staff privileges.

IRS – Internal Revenue Service – investigates potential violations of the Internal Revenue Code (

Having recognized that such scrutinizing entities exist, and who they are, the next question becomes, how does one deal with such scrutiny? How does one actually succeed? How does one ever overcome the scrutiny represented by these acronyms? In simple terms, physicians and PA’s need to recognize that they cannot succeed alone. They cannot proceed as small, individual “kingdoms”, working with limited resources and antiquated thoughts. Physicians and PA’s need to embrace both traditional allies, and form new alliances. Traditional allies may be in the form of organized medicine – whether it be a medical society, a specialty society, a medical staff – or even simply a group of local providers coming together to make joint purchases of either goods or services. Physicians and PA’s need to set aside their traditional individuality for a new shared goal – success.

Yet, “success” today also requires the stark realization that medical practices cannot continue as in the past. Outdated technologies and part-time staff with little or no formal training guarantee only failure. New tools in the form of high-tech, routine, expert compliance services must become the norm for every medical practice as an effective counter-measure.  Additionally, as a tool to be used in dealing with the Internal Revenue Service, physicians and PA’s must embrace the expertise, and intervention, of experienced accountants and even certified coding experts, as a tool against potential false claims, fraud and/or audit investigations. In any of these arenas, a physician or PA absolutely must have the counsel of an experienced healthcare attorney, or risk multiple, and severe, consequences.

While physicians and PA’s are seemingly failing every day, the situation is not yet lost. However, it is time to proceed in new ways, with new and old allies, to be prepared with new tools and come together, not as individuals, but as part of a well prepared team.  This is the only way to succeed under such intense scrutiny. To do otherwise will only endanger your hard earned license and reputation.

Kern Augustine, P.C., Attorneys to Health Professionals,, is solely devoted to the representation and defense of physicians and other health care professionals. Thomas Gallo may be contacted at 1-800-445-0954 or via email at