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...
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... 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.
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.
Pozgar, G.D. (2012). Legal Aspects of Health Care Administration. United States of America: Jones and Bartlett Learning, LLC.
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
Chapter fifteen in Legal Aspects of Health Care Administration by George D. Pozgar covered a major topic in health care. I found this chapter the most attention-grabbing of the options given to the students to base their paper on.
Pozgar, G. (2012). Legal Aspects of Health Care Administration. Sudbury, MA: Jones & Bartlett Learning.
Court stated that “if a hospital functions as a business institution, by charging and receiving money for what it offers, it must be a business establishment also in meeting obligations it incurs in running that establishment.”
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.
Throughout history there have been many white collar crimes. These crimes are defined as non-violent and financial-based crimes that are full ranges of fraud committed by business and government professionals. These crimes are not victimless nor unnoticed. A single scandal can destroy a company and can lose investors millions of dollars. Today, fraud schemes are more sophisticated than ever, and through studying: Enron, LIBOR, Albert Wiggan and Chase National Bank, Lehman Brothers and Madoff, we find how the culprits started there deception, the aftermath of the scandal and what our country has done to prevent future scandals.
Forrester, K., & Griffiths, D. (2010). Essentials of law for health professionals. Sydney: Mosby Elsevier. Retrieved from Google Books.
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...
Davidson, Stephen M. Still Broken: Understanding the U.S. Health Care System. Stanford, CA: Stanford Business, 2010. Print.
The major implication of this decision is that each state decides the type of evidence required to withhold or withdraw medical treatment from an incompetent patient. The state ...
Westrick, S. (2013). Legal and Ethical Issues in Healthcare. Burlington, MA: Jones & Bartlett Learning.
Module two deals with external influences in healthcare administration and the conflicts that may cause lack of growth in the organization. External influences can range from society, stakeholders, staff, and patients. Health administrators should be in agreement with staff and physicians to maintain proper ethics and safety for everyone. Society has a big influence of healthcare organizations with spending their money towards health insurance, medication, treatment services and exams. As long the healthcare organization has a well reputation built on trust, then consumers will spend on that healthcare organization. The stakeholders that take part in external influences on ethics are the vendors, technology specialists, maintenance, insurance
Barton, P.L. (2010). Understanding the U.S. health services system. (4th ed). Chicago, IL: Health Administration Press.