The cost of healthcare fraud is tens of thousands of dollars every year. The Federal Government have had to put fraud and abuse laws into place due to this. While most healthcare providers are in their fields to benefit patients and receive honest pay for their services rendered, there are also some deceitful healthcare providers who are the reason the fraud and abuse laws came about, and physicians are expected to abide by said laws. False Claims Act (FCA), Anti-Kickback Statute (AKS), Physician Self-Referral Law (also known as Stark Law), Social Security Act (includes the Exclusion Statute and the Civil Monetary Penalties Law (CMPL)), and United States Criminal Code make up these fraud and abuse laws (Medicare Learning Network, 2017). …show more content…
If any individual knowingly files or has any source in the filing of a false claim, then they are in violation of this law. They may receive a fine and/or sentencing dependent on the charge. Under the Anti-Kickback Statute (AKS), if an individual receives or gives anything of value in exchange for services or products that are reimbursable by a Federal healthcare program knowingly, then they are in violation of the AKS law. The charges under this law could be a fine up to $74,792 as od 2017 for civil violations (Medicare Learning Network, 2017). The Physician Self-Referral Law (Stark Law) bans providers from sending patients to another entity in which the physician or immediate family receives monetary gain. If found in violation of this law, providers are subject to fines, providing repayment of services paid for and possible elimination from all Federal healthcare programs. The Criminal Health Care Fraud Statute bars defrauding any benefit healthcare programs or receiving monetary gain by any health care benefit plan knowingly. Violators could be subject to fines and/or imprisonment (Medicare Learning Network,
Anti-Kickback Statute prohibits anyone knowingly or willfully offering, paying or soliciting or receiving remuneration, directly or indirectly; in cash or kind; in exchange for; patient referrals or furnishing or arranging a good or service for a Federal healthcare program including Medicare or Medicaid. Stark would also apply to Hanlester as well but Stark was not enacted until after the Hanlester case. Stark is strict liability, does not require the knowingly/willfully element, and is not prosecuted criminally.
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...
HIPAA and fraud & abuse tie together in the way HIPAA protects the use the PHI in the billing and coding of claim form. No matter if the patient sells their information, HIPAA is there to help protect against fraud and abuse. One way HIPAA helps prevent fraud and abuse is in the case of preforming an audit. Although the government is the top payer in the US. Payers are the ones who do the audit of the offices. They make sure that what is on the claim matches what is on the patient’s record. This is how fraud and abuse can be stopped from continuing on.
The children had incurred numerous needles and painful hospital admissions, investigations, and procedures because of a false story and factitious signs...the falsification was not by the patient themselves but by another person "acting on their behalf" which is a proxy (502).
The big reason that physical therapists illegally charge patients extra on their insurance bill is because it is simple for them to do. Eric Ries said in Addressing the ‘Biggest Threat’ to Physical Therapy, “Remember that regardless of who does the billing, physical therapists and physical therapist assistants have a responsibility to make sure what they are documenting is accurate”(Ries 6). This makes it tempting for physical
MACs are responsible for doing prepayment medical reviews on Medicare claims to make sure that the services are medically necessary and that the beneficiary has coverage. RACs use data mining activities to look for Medicare claims that may have been improperly overpaid or underpaid. ZPICs use medical review, evidence-based policies, and data analysis to identify possible abuse, fraud, and waste in Medicare claims. Agencies that focus on Medicaid claims include MICs(Medicaid Integrity Contractors), Medicaid RAC (Medicaid Recovery Audit Contractors), MFCU (Medicaid Fraud Control Unit), OMIGs (State Offices of Medicaid Inspector General), and PERM (Payment Error Rate Measurement). MICs work with the Medicaid Integrity Program of the Social Security Act to audit claims for over payment. They also provide education to providers on payment integrity. Medicaid RACs look for over-payment and underpayment of Medicaid claims and report possible instances of fraud and criminal activity. The MFCU is certified by the secretary of HHS and conduct state initiative to investigate and prosecute providers who have defrauded the Medicaid claims system. OMIGs work within each state to improve the state Medicaid program integrity and help coordinate fraud and abuse activities that span
Medicare was designed as a universal healthcare program for individuals 65 years old and older. This program is funded by Medicare taxes and general federal funding withholding taxes. Medicare is a partnership between federal and state with the goal to provide medical insurance to the elderly that is poor and disabled. Generally all people who are 65 years or older and qualify for social security will automatically qualify for Medicare.
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...
There are several issues concerning the uninsured and underinsured patient population in America. There are many areas of concern the congressional efforts to increase the availability of health insurance, the public image of the insurance industry illustrated by the movie "John Q", the lack of good management tools, and creating health insurance coverage for all low income Americans. Since the number of uninsured Americans has risen to 43 million from 37 million in the flourishing 1990s and could shoot up even more severely if the economy continues to decrease and health care premiums keep increasing (Insurance No Simple Fix, 2001).
There is an ongoing debate on the topic of how to fix the health care system in America. Some believe that there should be a Single Payer system that ensures all health care costs are covered by the government, and the people that want a Public Option system believe that there should be no government interference with paying for individual’s health care costs. In 1993, President Bill Clinton introduced the Health Security Act. Its goal was to provide universal health care for America. There was a lot of controversy throughout the nation whether this Act was going in the right direction, and in 1994, the Act died. Since then there have been multiple other attempts to fix the health care situation, but those attempts have not succeeded. The Affordable Care Act was passed in the senate on December 24, 2009, and passed in the house on March 21, 2010. President Obama signed it into law on March 23 (Obamacare Facts). This indeed was a step forward to end the debate about health care, and began to establish the middle ground for people in America. In order for America to stay on track to rebuild the health care system, we need to keep going in the same direction and expand our horizons by keeping and adding on to the Affordable Care Act so every citizen is content.
...ue to numerous medical errors. With the amount of medical errors that currently do occur which is a current health care issue it cost the health care billions of dollar each year to fix the mistakes that were made.
Health care has always been an interesting topic all over the world. Voltaire once said, “The art of medicine consists of amusing the patient while nature cures the disease.” It may seem like health care that nothing gets accomplished in different health care systems, but ultimately many trying to cures diseases and improve health care systems.