click to edit title
the legal framework
click to edit
federal grant accounting principles (OMB circulars)
Health Care Quality Improvement Act of 1986 (also called Health Care Anti-trust)
falsification of medical records; criminal prosecution
laws that protect against fraud
The “Anti-kickback Statute” (1972 and subsequent updates) a criminal statute that prohibits a medical professional or health care organization from receiving or offering payment for a referral (any item or service of any value)
the anti-kickback statute is far broader and affects anyone engaging in business with a federal health care program.
the anti-kickback statute requires specific intent
The False Claims Act (1986 amendments) fraudulent requests for payment
healthcare fraud
white collar crime
committed by business and government professionals.
local, state and federal
Ethics in Patient Referrals Act of 1989 (inclusive of “Stark laws”) prohibits self-referral of any patient treated under Medicare or Medicaid. effect them only
CIVIL charges
aka The Physician Self-Referral Law,
Sarbanes-Oxley (SOX) Act also pertains to financial reporting of publicly traded companies
From the readings and independent research, find one (1) specific real life legal case example of how kickback arrangements would violate the Stark Law.
how the kickback arrangements could violate trust between provider organizations and patients.
find one (1) specific real life legal case example of a breach of the False Claims Act by a health-related organization.
In addition, discuss whether the health care organizations in this example is properly equipped to ensure compliance and minimize exposure risks. If not why not?
The most significant risk centers on billing and coding of services for reimbursement from Medicare. No one can review every bill or watch over every employee, but basic compliance principles can be adopted to minimize risks. As always, documentation and internal controls are key to ensure compliance ...
There are several things you can do to reduce the risk of False Claims Act liability. First, you should make sure you understand the rules that relate to the services and goods being billed. Information contained in any claim must be as accurate and complete as possible
Overall, I think that organizations are properly equipped to ensure compliance and minimize exposure risk. There is an existing law that outlines what healthcare organizations are allowed to do and not do when it comes to fraud waste and abuse of government resources and it is up to health care organizations to comply .
applies only to physicians who refer Medicare and Medicaid patients for specific services (“designated health services,” or DHS) to entities with which they (or an immediate family member) have a “financial relationship.”
a prosecutor will evaluate the facts and circumstances to make that determination.
critical definitions
what the law is implying