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Laws on Health Care Fraud in the United States Abstract: Health care fraud has drastically increased in number and extent in United States during the past several years. The main task of government is to manage the Health Care Fraud programs by providing national supervision and aid to maintain health care fraud investigations intending individuals and organizations that are deceiving the public and private health care systems. The FBI, in association with its federal, state and local law enforcement partners, the Centers for Medicare and Medicaid Services, and other government and privately-sponsored program participants, supervise closely together to tackle vulnerabilities, fraud, and abuse. This paper focuses on laws that have been enacted to fight against health care fraud in the United States today.
It examines the federal and state efforts to tackle this misuse. In present scenario, health Care Fraud has come up with full strength and it has drawn great attention from both the illicit and anti-criminal groups. Introduction: Health care fraud laws in the United States are multifaceted and often counterintuitive. Since 1993, great efforts are put by the Department of Justice to fight health care fraud in the health care industry on top priorities.
Government has to suffer a loss of billions of dollars due to Health care fraud from Medicare and Medicaid, which offer essential health care services to elderly, low income, and disabled Americans. Additionally, suppliers face the warning of harsh criminal and civil punishments in cases of suspected health care fraud. The federal government focuses on identifying and impeaching health care fraud in its health care insurance programs, Medicare and Medicaid. Effective laws passed to deal with fraud in these definite programs because it is government's one of the largest social program, (Ashe, 2005). A Comprehensive Program against Health Care Fraud: The Department of Justice takes a reasonable approach to skirmishing health care fraud. It works constantly to avert fraud by encouraging providers to control their own activities through compliance programs and by subsidizing consumer outreach initiatives, such as the consumer's fraud hotlines, to involve patients with first-hand knowledge in finding of fraudulent practices (Health Care Fraud Report, 1998).
The strategies of Justice Department strategy comprises of a strong civil and criminal enforcement program, built up under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and prevention efforts, which promote providers to espouse compliance programs and understand responsibility for monitoring their own activities. The best way to make stronger health care system in United States is by implementing the laws and promoting compliance and prevention (Health Care Fraud Report, 1998). The Health Care Fraud law, HIPAA is generally aimed at toward health care fraud in both the public and private sectors. Under HIPAA, the Health Care Fraud Statute provides for fines or custody for up to 10 years to criminal that intentionally executes, or tries to swindle any health care benefit program. Heavy Penalties are imposed when the fraud results in bodily harm or death. Those who Violates the Health Care Fraud Statute are subject to prosecution for money laundering, with an additional increase in potential sentence length.
In HIPAA amendment law, conviction under this statute subjects the individual to mandatory forfeiture of property that is directly or indirectly related to the offense. HIPAA need the Attorney General and the Secretary of HHS to set up a Health Care Fraud and Abuse Control Program (HCFAC), providing a harmonized national framework for federal, state, and local law enforcement agencies, the private sector, and the public to struggle health care fraud. The Program tries to accomplish the objectives such as to punish wrongdoing, to dissuade others from committing fraud, to guard patients against abuse and overlook, to shield the integrity of the Medicare Trust Fund, and other Federal health care programs, to edify patients and providers about the necessitate to thwart health care fraud and to promote compliance within the industry. To deal civil cases, the Department of justice obtains referrals from private whistleblowers bringing qui tam actions, other informers, and federal and state agencies. The Department cautiously inspects each referral to properly assess the liability of the health care provider and encourages providers to brief the liable government attorney on any factors which may have bearing on a case. Qui tam or whistle blower suits have noticeably augmented exposing of and monetary recoveries for health care fraud.
Under the FCA, in certain conditions private individuals can file an action on behalf of the United States, and gain part of any revival by the government in the action (Health Care Fraud Report, 1998). Laws in the United States to fight Health Care Fraud: The U. S. government took stern step observing the urgency and improves the quality of health care to combat health care fraud. Anti-Kickback Statue: This statute forbids any bribe, kickback, or rebate in return for the recommendation of patients covered by federal healthcare programs. In other words, It prohibits a person with intent offering, paying, soliciting, or receiving any compensation in return for referring a person for the stipulation of any item or service, or in return for purchasing, leasing, ordering, arranging or recommending the purchase, lease, or ordering of any good, facility, service, or item that is payable in whole or in part by a federal health care program.
Under the Anti-kickback Statute, payments to induce referrals for items or services that are reimbursable by federal health care programs are against the law. Civil and criminal penalties and exclusion from participation in the federal healthcare programs are imposed in violation of this law (Cotton, 1999). The Anti-kickback Statute could cause to be unlawful everyday practices such as practitioner or vendor price reductions to health plans, physician employment relationships with hospitals, and supplier discounts. Operation Restore Trust, launched by President Clinton in 1995 is a program that would significantly boost the federal governments allowance of financial and human resources to combat health care fraud. It was initially a two-year anti fraud plan intended to test the success of numerous innovations in fighting fraud in Medicare in California, Florida, Illinois, New York, and Texas (HCFA).
The Health Insurance Portability and Accountability Act of 1996 formed two new federal crimes: health care fraud and fake statements relating to health care matters. The health care fraud statute forbids the knowing or willful execution of a scheme to deceive any health care benefit program. The false statements statute prohibits knowingly and willfully falsifying, concealing, or covering up a material fact by any trick, scheme, devise, or making any materially false, fictitious, or fraudulent statement in relation with the release of or payment for healthcare benefits, items, or services. Violation of either statute is an offense and may result in fines or imprisonment (April 1998 10 K). Civil Rights of Institutionalized Persons Act of 1980 protect the rights of individuals who are institutionalized. The Civil Rights Division has played a significant role in protecting the rights of individuals in health care facilities and improving their conditions of confinement.
The Attorney General has the power to inspect conditions in public including nursing homes, mental health and mental retardation facilities, and to take corrective action where illegal activities take place and withdraw persons limited in the facilities of their constitutional or federal statutory rights (CFDA & NGA 1999). During FY 1998, the Civil Rights Division sustained its essential enforcement program under the Civil Rights of Institutionalized Persons Act (CRIPA) to remedy egregious conditions in public residential health care facilities. (Health Care Fraud Report, 1998). Racketeer Influenced and Corrupt Organizations Act (RICO) makes it an crime for any person associated with an enterprise engaged in throughway commerce to conduct the affairs of the enterprise through a pattern of racketeering activity (Cotton 1999). The RICO Act was initially formed to battle organized crime but at present it is used to fight health care fraud. In January 1999, the Supreme Court ruled that consumers could prosecute health insurers for damages under the federal racketeering law. This permits sufferers of health care fraud to recuperate triple the damages and their attorney fees (Burghardt 1999).
The Stark Law is imposed which tries to limit the physicians to get benefit from their referrals for a number of health services supposed to present high risks for abuse. The Stark Law intends to stop ownership or reparation arrangements that would not of necessity rise to the level of kickbacks under the Ant kickback Statute, but are nevertheless believed to have the potential to influence provider referrals. Contrasting the Anti-kickback Statute, thats main target is broad range of illegal transactions, the Stark Law is particularly directed toward physician referrals and is a civil, as opposed to a criminal, law. It indicates that the person who violates Stark Law is not subject to criminal prosecution, though they receive civil penalties and be barred from partaking in federal health care programs on the basis of Stark infractions. The Stark Law sanctions are mainly meant for billing entities, as opposed to referring doctors; because the prime remedy for a Stark violation is refutation of payment for an outlawed claim including mandated refund of funds improperly pay out in satisfaction of such a claim (Fabrikant, 1996). Stark I, or the "Ethics in Patient Referrals Act, " was acted out as a correction to the Omnibus Budget Reconciliation Act of 1989.
It took effect on January 1, 1992. Stark I only dealt with physician referrals of Medicare patients for clinical laboratory services when the referring physicians or their immediate family members had a financial interest with or in the provider of the clinical laboratory services. In 1993, the Stark legislation was extended to ban referrals of both Medicare and Medicaid patients to providers of 10 additional DHS. The amended self-referral legislation became effectual on January 1, 1995. Phase I of these regulations was available in the Federal Register as a final rule with comment period on January 4, 2001, and became functioning on January 4, 2002. The Phase II regulations took effect on July 26, 2004.
The Stark II regulations succeed the regulations issued in accord with the original Stark Law. In Phase III regulations, the law applies to dealings ranging from large investments in health care enterprises to...
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