Health care fraud is a form of white-collar crime. The 3 major laws that protect against healthcare fraud are the Anti-kickback statute (anyone), Stark Laws (Physicians), and the False Claims Act.
Many health care organizations are nonprofit and many physicians/health providers are salaried workers. Where are the vulnerabilities in the health system? This discussion will help you and your colleagues to gain an understanding of HCO and professional responsibilities.
To structure PART A (False Claims Act) of your post:
- State a hypothesis (key statement).
- Identify the specific law and its statute.
- From the readings and independent research, find one (1) specific CURRENT real-life legal case that can serve as an example of an HCO’s breach of the False Claims Act, a federal statute. (not sure if you want them to find adjudicated cases?)
- Note the violation. Does this violation relate to all payment programs (Medicare or Medicaid or Military or Railroad Workers or Indian Health Service or Ryan White) or just about specific ones?
- Discuss what would help health care organizations equip themselves to ensure compliance and minimize exposure risks like the one that you reported.
To structure PART B (Anti-Kickback Statute or Stark Law) of your post:
- State a hypothesis (key statement).
- Identify the specific law and its statute.
- From the readings and independent research, find one (1) specific CURRENT real-life legal case that can serve as an example of an HCO’s or health professional’s breach of the Anti-Kickback Statute or Stark Law, both federal statutes.
- Note the violation. Does this violation relate to all payment programs and all health providers or just specific ones?
- Discuss what would help HCO’s equip themselves to ensure compliance and minimize exposure risks like the one you reported.
To complete this post, you must read the background articles below. This discussion requires research beyond the articles. See Discussion Expectations and Grading for rules on discussions.
Assigned reading materials:
- Medicare Learning Network 2022 Publication: Medicare Fraud and Abuse PDF
- Supplemental Readings and Resources for Week 3: (Optional Resources to Read and/or Review)
- Medicare Learning Network 2021 Publication: Complying with Medical Record Documentation Requirements PDF
- Explore: CMS Program Integrity Manual 2021 Update Verifying Potential Errors and Taking Corrective Actions PDF
- UMGC Library Article: Health Care Quality Improvement Act (HCQIA) Healthcare – Considerations in Business Law PDF
See if you can find a disclosure form from a medical practice related to full disclosure to patients about referral options and the practice’s ownership of services. Patients would be asked to sign this form so they are fully informed and have patient treatment choices.
Note: What Federal Programs are covered by these laws: OIG Website: Fraud and Abuse Laws Landing Page
