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... hospital parking privileges Main principles personified within the statute are that most physician ownership in separate DHS entities, the services from which do not fall within the in-office ancillary services exception, is prohibited. Secondly, to meet the criteria for an exception, physician reimbursement usually must be at reasonable market value. At last, financial arrangements between physicians and other entities cannot reproduce the volume or value of referrals provided by a physician. The False Claims Act 23 is the primary of law health care fraud under which the federal government impeaches civil fraud against the United States. Accusations have usually involved up coding, billing for undelivered services, unbundling, misrepresenting material information, and certifying to the truth of false matters.
This Act was at first passed in 1863, during the Civil War. This Act forces civil and criminal legal responsibility on individuals that put forward false or fraudulent claims for compensation to the government. If violate this law, it may result in treble damages, civil monetary penalties, and ruling out from the Medicare and Medicaid programs (AHA 1998). The Medicaid False Claims Statute criminalizes false statements or representations in relation with any claim for benefits or payment, or the disposal of assets, under a federal health care program. While the Medicaid False Claims Statute was passed to aim false statements or representations specifically related to health care, the bulk of prosecutions linked to health care fraud continue to be brought under other statutes. Under the Medicaid False Claims Statute, the government must verify four elements to maintain a conviction that are (i) the defendant made, or caused to be made, a statement or representation of material fact in an application for payment or benefits under a federal health care program; (ii) the statement or representation was false; (iii) the defendant knowingly and willfully made the statement (Ashe, 2005).
The False Claims Act presents any person, including employees, beneficiaries, and coworkers, the right to file suit against individuals or entities who propose false claims to the government. A fine of $ 5500 to $ 11000 for each false claim filed, as well as 3 times the damages incurred by the government are imposed as a penalty for violating the False Claims Act. The Civil Monetary Penalties Statute has the right to enforce penalties of $ 10 000 per item of service, or in certain cases $ 50 000 and treble damages, on a person or entity for a range of offenses. These include intentionally presenting to a state or federal government claims for health care items or services, including up coded claims, that were not provided as submitted; fraudulent claims; a pattern of medically needless claims; and claims for physician's services that were not rendered by a licensed physician. Government agencies involve fighting Health Care Fraud Besides previous laws and regulations, there are other statutes and regulations accessible to government agencies in their attempts to combat health care fraud. Health care fraud imposes a huge cost to the health care system and to our nation's economy as a whole.
DOJ and HHS provide checking and enforcement of health care fraud regulations. Individual states help out the HHS Office of the Inspector General (OIG) and CMS to start and follow investigations of Medicare and Medicaid fraud. Persons and organizations that are certified by HHS to obtain payment under the Social Security Act are probable target for Medicare and Medicaid fraud investigations. OIG utilizes its permissive exclusion authority to induce providers to assist in the attempt to detect fraud through a voluntary disclosure program.
DOJ employs the resources of its own criminal and civil divisions, as well as those of the United States Attorneys' Offices and the FBI in prosecutions of fraud. The United States Congress' response to Medicare and Medicaid fraud that has strengthened to existing statutes and to pass new laws which must considerably boost the government's efforts to identify and fight health care fraud. This effect in a constitutional and regulatory scheme that creates civil and criminal sanctions for any person or legal entity that provides health care goods or services in a deceitful or offensive manner (Ashe, 2005). The Department of Justice depends profoundly on the investigative and audit work of various federal and state law enforcement agencies dedicated to deal with health care fraud, each with different experience, expertise and program knowledge. The key liability of law enforcement agencies with authority to examine health care fraud on particular health care programs shall not be construed to bar any federal investigative agency with jurisdiction from investigating fraud on any other health care program.
The Department of Health and Human Services and Office of Inspector General (HHS-OIG) spotlights primarily on fraud on the Medicare and Medicaid programs and the health benefits programs of the United States Public Health Service (PHS) such as the Indian Health Service. The main focus of Federal Bureau of Investigation (FBI) is on fraud of private health plans and on any health plan receiving federal funds such as Medicare, Medicaid, the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), and the Federal Employees Health Benefits Program (FEHBP). The Defense Criminal Investigative Service (DCIS), the investigative arm of the Office of the Inspector General), Department of Defense (DoD), is liable for investigating suspected fraud in DoD programs. The programs include those which provide health care to active duty and retired military personnel, their dependents and survivors through direct care provided by a military medical treatment facility; and civilian care provided through a health insurance program known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). The DCIS has major investigative jurisdiction of all allegations of fraud committed by health care providers throughout the DoD Military Health Services System. The Office of Inspector General of the Office of Personnel Management (OPM-IG) centers on fraud on the FEHBP, which offers health reimbursement to federal civilian employees, retirees, and their dependents.
The main purpose of The Office of Inspector General of the Department of Labor (DOL-OIG) is to detect health care fraud in three major Federal health benefit and disability program administered by DOL that pay off or provide benefits to Federal workers and certain coal miners and long-shore / harbor workers, who uphold job-related injuries, illnesses or diseases. DOL-OIG devotes considerable attention to fraud within private sector health and welfare benefit plans keeping up under the Employee Retirement Income Security Act. Other federal agencies which investigate fraud by health care providers within their respective jurisdictions are the Internal Revenue Service of the United States Department of the Treasury, Federal Trade Communication, and the United States Postal Inspectors. Federal, State and local investigative agencies work as associates with each other.
Almost all of the states have Medicaid Fraud Control Units (Mfcus). The Mfcus are accountable for the examination and prosecution of all criminal violations of state laws with reference to fraud on the Medicaid program, as well as the investigation and prosecution of patient abuse and overlook in Medicaid-funded facilities. The Mfcus are certified by HHS-OIG and are required by federal law and regulation to meet definite minimum standards, including the employment of a multi-disciplinary team of attorneys, auditors, and investigators. State Attorneys General may have jurisdiction to investigate health care fraud offenses under state law (John T. Floyd Law Firm, 2007). Conclusion: Health care fraud is wide spread in United States and existing law must be implemented effectively to curb the situation that can arise due to fraudulent activities.
The swiftness of legislative change is varying the scenery of health care release and payment, presents new confronts that must be designed for, both in deterrence and enforcement efforts. The Department of Justice is making every possible attempt to face challenge and planning in the future to modify actions of health care businesses so that they can take corrective measures to check health care fraud schemes, while keeping enforcement efforts aware of the adverse impact of provider's conduct on the welfare of their patients. The important federal statutes and regulations must be used to combat health care fraud in the United States. There are other universal criminal and civil statutes applied to fraudulent health care transactions and arrangements in addition to laws and regulations that are specifically directed toward health care fraud. The majority of states have legislation aimed at health care fraud that may be more or less severe than the governing federal law. References: 1) Janine Catherine Ashe, Kimberly Hope Levy, Alissa M.
Name; American Criminal Law Review, Vol. 42, 2005. 2) Health Care Fraud Report, Fiscal Year 1998, web 3) Burghardt, Heather. 1999. RICO Cause of Action Against MCOs. Humana Inc. v. Forsyth. American Journal of Law and Medicine. 4) CFDA (Catalog of Federal Domestic Assistance).
Civil Rights of Institutionalized Persons. web 1999. 5) AHA (American Hospital Association). Health Care Fraud Report Fiscal Year 1997. (U. S. Justice Department) published 10 / 21 / 98, web 6) Cotton & Company, LLP. 1999 Brief Synopses of Major Government Fraud Statutes. web 1999. 7) Fabrikant R, Ka Ib PE, Hopson MD, By PH. 1996.
Health care fraud: enforcement and compliance. New York, NY: Law Journal Press. : 4. 05 [ 5 ]. 8) John T. Floyd Law Firm. 2007. web Outline Laws on Health Care Fraud in the United States I) Introduction: 1) Fighting fraud in the health care industry one of the Department's top priorities II) A Comprehensive Program against Health Care Fraud: The Department's strategy consists of two components: a strong civil and criminal enforcement program. -The Health Insurance Portability and Accountability Act of 1996 (HIPAA). 2) Qui tam III) Laws in the United States to fight Health Care Fraud: 1) Civil Rights of Institutionalized Persons Act of 1980 2) Racketeer Influenced and Corrupt Organizations Act (RICO): 3) Anti-Kickback Statue 4) The Stark Law 5) Ethics in Patient Referrals Act 6) The False Claims Act 7) Under the Civil Monetary Penalties Statute, IV) Government agencies involve to fight Health Care Fraud Government agencies in doing their efforts to combat health care fraud. DOJ and HHS provide monitoring and enforcement of health care fraud.
State and Local Investigative Agencies- Medicaid Fraud Control Units certified by HHS-OIG. V) Conclusion Health care fraud is a great challenge to Department of justice. Continuous amendments in laws are required to combat this big battle.
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