Part 1: Interplay between Peer Review and Compliance, False Claims Act, and Stark Law

Episode Date: September 21, 2022

In this episode of Stark Integrity, Bob Wade (“Captain Integrity”) examines the interplay between peer review and compliance functions—particularly how they intersect with the False Claims Act (FCA) and the Stark Law.

Bob explains how physician conduct, quality issues, and billing concerns can overlap across departments, creating both operational challenges and compliance risks.

Understanding Peer Review vs. Compliance

Bob begins by distinguishing between peer review and compliance:

• Peer Review focuses on:
  • Quality of care
  • Clinical decision-making
  • Physician performance
• Compliance focuses on:
  • Billing accuracy
  • Regulatory adherence
  • Fraud and abuse prevention

While these functions are distinct, Bob emphasizes that they often overlap in practice.

Where the Interplay Occurs

A key theme of the episode is that issues identified in peer review can create compliance exposure.

Bob explains that:

• Physician behavior reviewed for quality purposes can also raise FCA concerns
• Certain peer review findings may indicate improper billing or documentation
• Some cases may implicate Stark Law violations or referral issues

In other words, a clinical issue can quickly become a legal issue.

Peer Review Findings and FCA Risk

Bob highlights that peer review activity can uncover conduct that rises to the level of a false claim.

Examples include:

• Medically unnecessary services
• Improper documentation supporting claims
• Patterns of care that could impact reimbursement

These issues may trigger liability under the False Claims Act, even if initially identified as quality concerns.

Coordination Between Departments

One of Bob’s central messages is that peer review and compliance functions must work together.

He emphasizes:

• The need for training teams to recognize crossover issues
• The importance of communication between departments
• The necessity of deciding which function takes the lead on a given issue

Organizations should not treat these functions as silos—doing so can lead to missed risks.

Access to Peer Review Information

Bob also discusses how peer review information can be shared appropriately within the organization.

He notes that:

• Certain peer review findings may need to be reviewed by compliance personnel
• Organizations must balance confidentiality protections with regulatory obligations
• Internal processes should define when escalation is required

This is particularly important when issues may involve potential fraud or reimbursement concerns.

Identifying and Escalating Issues

Bob emphasizes the importance of having a clear process for identifying and escalating issues.

Organizations should:

• Evaluate whether an issue is clinical, compliance-related, or both
• Assign responsibility for review and follow-up
• Ensure timely escalation when legal or regulatory risks are present

Failing to properly classify and escalate issues can lead to significant liability exposure.

Practical Tools and Systems

Bob briefly touches on tools organizations may use, such as:

• Incident reporting systems (e.g., Midas)
• Internal audit processes
• Documentation and tracking mechanisms

These systems can help capture issues early and ensure they are routed to the appropriate team.

Training and Culture

A critical takeaway from this episode is the importance of training and organizational culture.

Bob stresses that:

• Staff should understand both peer review and compliance perspectives
• Teams must be trained to recognize when issues cross over
• Leadership should foster a culture of accountability and transparency

A well-trained organization is far better equipped to manage these risks.

Practical Takeaways

The key takeaway from this episode is that peer review and compliance are deeply interconnected. Organizations should:

• Break down silos between departments
• Train staff to recognize FCA and Stark implications
• Establish clear escalation protocols
• Monitor both clinical and billing practices
• Ensure proper documentation and follow-through

Final Thoughts

Bob Wade’s discussion highlights a critical reality in healthcare compliance: quality and compliance cannot be separated.

The interplay between peer review and compliance creates both challenges and opportunities. Organizations that effectively coordinate these functions will be better positioned to identify risks early, ensure compliance, and maintain high standards of care.

Click here to listen to this Stark Integrity Podcast Episode:
https://podcasts.apple.com/us/podcast/part-1-interplay-between-peer-review-and-compliance/id1588939373?i=1000580138077&l=fr-FR