Module 05 Assignment - Fraud and Abuse LawsAAAA
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Rasmussen College *
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05
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Medicine
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Apr 3, 2024
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docx
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Module 05 Assignment - Fraud and Abuse Laws
Instructions:
Read each scenario and decide if the actions taken by the company are considered fraudulent. After each scenario, state what law(s)/rule(s) were violated and explain your reasoning.
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In June 2018, Healogics, Inc. agreed to pay up to $22.5 million to settle civil FCA allegations that it knowingly caused wound care centers to bill Medicare for medically unnecessary services. Healogics, a Florida-based company, manages nearly 700 hospital-based wound care centers across the country. Medicare covers hyperbaric oxygen therapy (HBO), a modality in which the entire body is exposed to oxygen under increased atmospheric pressure, as an adjunctive therapy to treat certain chronic wounds. The settlement resolved allegations that from 2010 through 2015, Healogics knowingly submitted or caused the submission of false claims to Medicare for medically unnecessary or unreasonable HBO therapy.
a.
Healogics violated the False Claims Act, according to the Justice Department. I feel they purposefully billed Medicare for needless medical treatments. The federal civil False Claims Act forbids submitting bogus claims to the Medicare or Medicaid systems. The law does not need intention.If the therapeutic services provided were not reasonable or essential for the patient's treatment, it would be termed fraudulent. The act includes the
False Claims Act.
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In June 2018, Health Quest Systems, Inc., Health Quest Medical Practice, P.C. ("HQMP''), Health Quest Urgent Medical Care Practice, P.C., ("HQUC") (collectively "Health Quest''); and Putnam Health Center ("PHC") entered into a settlement agreement to resolve their FCA liability. From April 1, 2009 through June 23, 2015, Health Quest submitted claims for evaluation and management services but did not sufficiently document the services to support the level of service billed. As a result, the services were billed two levels higher than supported by the medical record. From April 1, 2011 through August 2014, Health Quest submitted claims for home health services that lacked sufficient medical records to support the claim, including documentation of a face-to-face encounter with a physician. From March 1, 2014 through December 31, 2014, Health Quest subsidiary hospital, PHC, submitted allegedly false claims for inpatient and outpatient services referred to PHC by two orthopedic physicians. The two physicians had a direct financial relationship with PHC for providing administrative services and received compensation from PHC. The United States alleged their compensation exceeded the fair market value for the services. The United States further alleged that one purpose of the excessive compensation was to induce the above referrals to PHC. Health Quest and PHC agreed to pay $15.6 million and enter into a 5-year CIA.
a.
This appears to be a violation of the False Claims Act or medical abuse, in my opinion. Medical abuse, either deliberate or inadvertent, occurs when your staff fabricates claims for financial advantage.Intentional or inadvertent.
This was a fraudulent instance as Health Quest failed to adequately document services and submitted claims for home services without medical proof from the physician.
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In November 2017, a coder at Livewell Medical Center was investigated during an audit. It was discovered that the coder was asked by their manager to bill separately for a group of procedures that would normally be billed under one single comprehensive code in order to increase revenue for the medical center. The coder did not comply with their manager’s request and continued to maintain the integrity of the codes.
a.
Although the coder had no intention of breaking any laws, the manager was aware of the issue and took action. We believe no laws were breached in this case.
If the coder followed the manager's suggestion, it would have been regarded fraudulent. The coder created fake records on the institution's health programs to increase income. Billing or coding errors, whether clerical or not, are considered fraud. The law in question would fall under
the False Claims Act.
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In September 2018, the District Court for the Eastern District of Missouri entered a civil judgment in the amount of $5.5 million against a neurosurgeon, his fiancée, and their professional corporations DS Medical and Midwest Neurosurgeons. The government’s complaint and evidence at trial established that the neurosurgeon, who practiced through his professional corporation Midwest Neurosurgeons, used spinal implants when performing spinal fusion surgeries. His fiancée started a spinal implant distributorship business called DS Medical in November 2008, after which he began using DS Medical as his spinal implant distributor for most
of his spinal implant surgeries from 2009 through 2012. His fiancée then received commissions on the expensive implants that he purchased from her company.
a.
Yes, there were violations of the law in this case. The court found that the pair violated anti-
kickback rules by conspiring to seek and collect illicit kickbacks.
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A release of information specialist at RC Hospital received a phone call from the spouse of a patient, pleading for copies of her husband’s medical records. The release of information specialist did not have an authorization on file that was signed by the husband and did not have any paperwork on file to assume that the husband was incompetent and unable to sign for his own medical records. The release of information specialist informed the spouse that records could not be released without proper documentation and the patient’s information was protected.
a.
There were no laws broken, and the HIM specialist comlied with all HIPAA regulations,
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