Healthcare Finance & Reimbursement 8-1 Activity Fraud, Waste, and Abuse Reduction Memo
docx
keyboard_arrow_up
School
Southern New Hampshire University *
*We aren’t endorsed by this school
Course
630
Subject
Health Science
Date
Jan 9, 2024
Type
docx
Pages
5
Uploaded by HighnessValor5613
Nikkia A Bates Southern New Hampshire University IHP-630-Q1493 Healthcare Fin & Reimbursement Prof. Rebecca Arsenault
November 10, 2023
False Claims Act
The False Claims Act states that any person who knowingly submits a false claim for payment of
any sort to an officer or employee of the Government or Armed Forces of the United States is liable to a civil penalty (CMS, 2021). For example, a provider who knowingly submits a claim for reimbursement to government insurances such as Medicare for medical services not rendered will result in civil penalties (CMS, 2021). There are also other circumstances where the False Claims Act will apply, which include a health organization receiving money from the government they are not entitled to. For example, a health organization who receives payments from Medicare through the year and files a cost report at the end of the year to avoid submitting a refund payment to Medicare; will result in a civil penalty (CMS, 2021). There are serval different civil financial penalties that a health organization may face for violating the False Claims Act. Any person and or health organization that violates the FCA is liable to civil penalties of not less than $5,000 and not more than $10,000, plus more than 3 times the number of damages which the government sustained (CMS, 2021). Physician Self-Referral Law
The Physician Self-Referral Law also referred to as “Section 1877 of the Social Security Act (42 U.S.C. 1395nn), or Stark Law” forbids medical providers from making referrals for specific designated health services (DHS) payable, by Medicare to any health organization to which the medical provider has a financial relationship (ownership, investment, or compensation) with, unless an exception applies (CMS, 2023). Specific designated health services include but are not limited to; inpatient and outpatient hospital services, outpatient prescription drugs, clinical laboratory services, physical therapy services, occupational therapy services, radiology, and certain other imaging services, etc. (CMS, 2023). The Centers for Medicare and Medicaid
Services, also states that the law forbids those health organizations from submitting claims to Medicare for those “referred” services and provides several grants to create regulatory exceptions for financial relationships to avoid patient abuse (CMS, 2023). As stated, the overall purpose of the “Stark Law” is to prevent medical providers from providing referrals to patients for their financial interest versus the benefit of the patient. That said, the law helps to prevent fraud and abuse in healthcare by ensuring that the medical provider submits referrals based on the best interests of the patient. The law also ensures prevention of fraud and abuse by stating that health organizations should only receive reimbursements fir the services rendered and that patients are not referred to health organizations that will not be able to provide them with correct care. Anti-Kickback Statute
The Anti-Kickback Statute is a federal law that forbids the medical providers from knowingly offering or accepting financial “kickbacks” in exchange for patient referrals; this includes any services payable by Federal healthcare programs such as Medicare and Medicaid (HHS-Office of
Inspector General, n.d.). Although, both the Anti-Kickback Statue and the Physician Self-
Referral Law have major similarities the biggest difference is that; the Physician Self-Referral Law forbids medical providers from referring patients to health organizations in which the provider has a financial interest or investment whereas the Anti-Kickback Statue forbids physicians offering or accepting financial compensation for patient referrals.
Financial penalties for violation of the Anti-Kickback Statue include criminal penalties and administrative sanctions such as fines, jail time, and exclusion from Federal health insurance
programs (HHS-Office of Inspector General, n.d.). The fine the medical provider would face is
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
penalties of up to $50,000 per kickback plus three times the amount of the money paid for the services rendered (HHS-Office of Inspector General, n.d.).
Anti-Trust Laws
Antitrust laws are regulations that encourage competition by limiting the market power of any firm (Twin, 2023). The Anti-trust laws include the Sherman Act, the Federal Trade Commission Act, and the Clayton Act. These laws help to prevent fraud and abuse in healthcare by ensuring that healthcare providers cannot collude to fix prices or exclude competitors. The Anti-Trust Laws also help to ensure that healthcare consumers have access to a variety of providers and can choose the provider that best meets their needs.
Recommendations
There are several strategies and methods that can be taken to reduce operational risk and promote operational efficiencies by integrating the regulations that prevent fraud, waste, and abuse. One method would be to develop and implement policies and procedures that comply with these regulations. Another method is to provide training to employees on these regulations. The third method would be to utilize technology to automate compliance with these regulations.
References The false claims act (FCA) provides, in pertinent part, that. (n.d.). https://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/
SMD032207Att2.pdf
Fraud & abuse laws
. Office of Inspector General | Government Oversight | U.S. Department of Health and Human Services. (2021, October 5). https://oig.hhs.gov/compliance/physician-
education/fraud-abuse-laws/#:~:text=The%20AKS%20is%20a%20criminal,for
%20Medicare%20or%20Medicaid%20patients
Medicare Fraud & Abuse: Prevent, detect, report - centers for Medicare ... (2021, January). https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNProducts/Downloads/Fraud-Abuse-MLN4649244.pdf
Physician self-referral
. CMS.gov. (2023, September 6). https://www.cms.gov/medicare/regulations-guidance/physician-self-
referral#:~:text=Prohibits%20a%20physician%20from%20making,)%2C%20unless%20an
%20exception%20applies
Twin, A. (2023, January 31). Antitrust laws: What they are, how they work, major examples
. Investopedia. https://www.investopedia.com/terms/a/antitrust.asp#:~:text=Antitrust
%20laws%20were%20designed%20to,the%20history%20of%20antitrust%20regulation
.