DCano_FraudAbuse_020822
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Rasmussen College *
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M120/HSC15
Subject
Medicine
Date
Jan 9, 2024
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Uploaded by BarristerMoonPorcupine45
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.
1.
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.
Law violated is qui tam. Qui tam allows citizens with knowledge of fraud against the
government.
2.
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.
the qui tam law was violated. Documents were not documented sufficiently; the government
will recover funds lost to fraud.
3.
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.
The false claims act. If billed as a bundle, the government will pay less than if the codes were
billed individually.
4.
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.
The anti-kickback law was violated. The providers’ decisions were made on self-interests
rather than the quality of care or necessity of services.
5.
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.
HIPAA privacy and security rules. Patient records should only be released to people they have
signed off on.
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