In the United States, healthcare fraud and abuse are significant factor associated with increasing health care costs. It is estimated that federal government spends billions of dollars on the health care cost (Edwards & DeHaven, 2009). Despite the seriousness of fraud and abuse offenses, increasing numbers of healthcare providers are seeking new and more profitable ways to build business relationships. These relationships include hospital mergers, hospital-physician joint ventures, and different types of hospital-affiliated physician networks to cover the rising cost of health care (Showalter, 2007, p 111-114). When these types of arrangements are made, legal issues surrounding the relationship often raise. There are five important Federal fraud and abuse laws that apply to the relationship and to physicians are the False Claims Act (FCA), the Anti-Kickback Statute (AKS), the Physician Self-Referral Law (Stark law), the Exclusion Authorities, and the Civil Monetary Penalties Law (CMPL) and (Office of Inspector General (OIG), 2010). Out of five most important laws that apply to the relationship and the physicians, we are going to focus on the Anti-Kickback Statute (AKS) and the Physician Self-Referral Law (Stark law). What is Anti-Kickback Statute and Self-Referral law? The Federal Anti-Kickback Statute is a criminal statute that prohibits any person or business entity from making or accepting payment of any type of compensation to increase referrals for health services that are reimbursable by the federally-funded health care program including Medicare and Medicaid. Since the anti-kickback statute is a criminal statute, violations of it are considered felonies, with criminal penalties of up to $25,000 in fines and fi... ... middle of paper ... ... Fraud and Abuse in Federal Programs Retrieved from Cato Institute website http://www.downsizinggovernment.org/fraud-and- abuse Office of Inspector General. (2010). A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse. Retrieved from DHHS Publication http://oig.hhs.gov/compliance/physician-education/index.asp Oh, J. (2011). Anti-Kickback Cases Involving Hospitals in 2010 and 2011. Becker’s ASC Review. Retrieved from http://www.beckersasc.com/stark-act-and-fraud-abuse-issues/10 big-anti- kickback-cases-involving-hospitals-in-2010.html Showalter, J. S. (2007). Southwick’s the law of hospital & health care administration, 5th ed. Chicago: Health Adm. Press Watnik, R. (2000). Antikickback versus stark: what's the difference?. Healthcare Financial Management: Journal of the Healthcare Financial Management Association, 54(3), 66-67.
The Hospitals medical staff including on call- physician and their designees should be made aware of Hospital bylaws or policies and procedures.
While working at the OB-GYN department in the hospital, Dr. Vandall, as a Vice Chair of the Department of Obstetrics and Gynecology, learned that another employee of the hospital, Dr. Margaret Nordell was engaged in a level of treatment that was unethical and violated accepted standards of care. It was his duty to the hospital and to the patients, to monitor the competence of his staff members. Although he tried to take the proper steps to deal with it within the hospital, he ended up reporting this to the North Dakota Board of Medical Examiners. It was concluded by the Board that the treatment of Dr. Nordell was gross negligence and they suspended her license to practice medicine.
Violations of Stark can come at a hefty price. The statute provides for the following sanctions on claims submitted for DHS in violation of Stark: (1) denial of payment; (2) requiring refund of funds received; (3) civil penalties of $15,000 per service if the violation is knowing; and (4) exclusion from Medicare or Medicaid programs where a physician or entity knowingly enters into an improper cross-referral arrangement or scheme in order to skirt the self-referral
In the case of Tomcik v. Ohio Dep’t of Rehabilitation & Correction, the main issue present was the medical negligence demonstrated by the staff of the medical clinic at the Ohio Department of Rehabilitation and Correction towards the inmate Tomcik. Specifically, nonfeasance, or the “failure to act, when there is a duty to act as a reasonably prudent person would in similar circumstances” (Pozgar, 2016, p. 192), was displayed when the employees at the medical clinic failed to give immediate medical attention to Tomcik when she continually signed the clinic list and “provided the reason she was requesting
Some federal statutes address fraud in government health care programs, and many of these laws vary considerably (Krause 2004). Some of these laws specifically target health care fraud. Example of the laws that the government direct at inappropriate health care activities includes the “Medicare and Medicaid Anti-Kickback Statute and Ethics in Patient Referrals Act (EPRA).”
One of the biggest contributors to health care costs that I have seen during my time in the healthcare industry is insurance fraud. One example of such fraud came about two months ago. I was taking a phone call from a provider that was upset that one of their claims had denied even though all of their previous claims had been paid. In researching with a partner plan it was determined that the claim denied because this medical provid...
Rodwin, M. (1996). Consumer protection and managed care: issues, reform proposals, and trade-offs. Houston Law Review, 32(1319), 1319-1381
Niles, N. J. (2011). Basics of the U.S. health care system. Sudbury, MA: Jones and Bartlett.
Health care fraud is an ever growing problem with in our country. This is not a new issue, nor an issue that will ever go way. According to the Federal Bureau of Investigations (FBI) health care fraud cost tax payers two hundred and seventy two billion dollars in 2013 (Federal Bureau of Investigations, 2016). The numbers have continued to increase. When discussing health care fraud we need to know what exactly we are discussing.
Medicare fraud occurs when healthcare providers, suppliers, and private companies charge for services or supplies patients never receive. Additionally, abuse of the Medicare program also occurs because physicians and suppliers do not always follow best medical practices which leads to excessive costs through improper payments, or medically unnecessary services, both of which abuse the program. Conservative estimates suggest he...
In what is known as the largest malpractice case in Maryland is the case of Enso Martinez and Rebecca Fielding against John Hopkins Hospital. In this situation, Ms. Fielding was taken to the hospital for an emergency caesarean section. Grant...
His main contention being that the very permissive attitudes within society allow for this type of crime to continue to flourish without consequence; but, research has shown that Americans do in fact condemn white collar crime. There has been a lot issues with the true definition of what white collar crime is. The most common white-collar crimes include fraud, bribery, Ponzi schemes, cybercrime, copyright infringement, money laundering, identity theft and forgery insider trading, labor racketeering, embezzlement. Although Sutherland defined it first, the FBI defines it with a more narrow approach: "those illegal acts which are characterized by deceit, concealment, or violation of trust and which are not dependent upon the application or threat of physical force or violence" (1989, 3). The crimes committed which fall under the title of white collar crime are entirely dependent upon the identity of the offender; their occupation, their environment, and their opportunities are significant factors in relation to their
Lublin, J. S., & Carrns, A. (2003, April 11). Directors had lucrative links at HealthSouth. Wall Street Journal. p. B1. Retrieved from: http://search.proquest.com.proxy1.ncu.edu/docview/398944990?accountid=28180
...question is what is the government doing to prevent further fraud? Perhaps the law "Dodd Frank” went into effect profoundly changing financial reform and consumer protection in financial services. Besides, applying strong supervision and regulation of financial firms and financial reform required for the first time, that hedge fund adviser (and other asset funds) to register with the SEC and subject to the obligation to provide information about its operations and portfolios as it are necessary to assess the risk. The new law also creates the "Office of Financial Research" in the Treasury whose staff will be composed of experts with highly sophisticated knowledge that will support the Council's work by collecting financial data and conducting economic analysis. The question remains will this financial reform will to prosecute white collar criminals or prevent fraud.
Zero in on a 45 year-old mother of 13. A man comes to her with a proposal. Invest in his company, and he can guarantee 100%, 200%, possibly even 300% returns on what she gives in mere months. For her this means taking out a second mortgage on her house; the same house she hopes to pay off entirely with the promised large return on her investment. Two years later, the windows of the house are boarded up and the woman recounts to reporters the chilling details behind the reason her family has no place to spend Thanksgiving this year. Her money is gone, along with her hopes of ever retiring from the two jobs she works. Stories like this are heard all too often from victims of white-collar crime. “Lying, cheating, and stealing. That’s white-collar crime in a nutshell. The term- reportedly coined in 1939- is now synonymous with the full range of frauds committed by business and government professionals” (FBI, n.d.). White-collar criminals are not holding a gun to anyone’s back demanding wallets and valuables. Instead, they gain the trust of those they prey on. Worse, they use their status in society to build comfort in their victims’ minds. A few of the best-known schemes in U.S. history are Enron, WorldCom, and the massive Bernie Madoff Ponzi scheme. These three cases alone amount to losses upwards of 70 billion dollars. The victims in each case are the same, American citizens. White-collar crime in America is insufficiently controlled due to weak laws, a broad pool of victims, and the enormous power scale of those involved.