Summative Assessment Fraud and Abuse Enforcement MHA508 Wk 3 (1)
docx
keyboard_arrow_up
School
University of Phoenix *
*We aren’t endorsed by this school
Course
508
Subject
Law
Date
Apr 3, 2024
Type
docx
Pages
6
Uploaded by BailiffProtonEel34
Running head: Summative Assessment: Fraud and Abuse Enforcement
1
Summative Assessment: Fraud and Abuse Enforcement Tramecia Manning
University of Phoenix
MHA/508: Navigating the Regulatory Environment in Health Care
December 5, 2023
Dr. Debra S. Sandberg
Running head: Summative Assessment: Fraud and Abuse Enforcement
2
Fraud, Wast and Abuse has become commonplace in the Healthcare sector especially in the settling of the Covid 19 Pandemic that shocked the World, but it also became the target to a lot of misuse in healthcare claims in the challenging times. Though health care fraud is egregious
all its own but the acts the used the Covid 19 pandemic to defraud the health care sector when the system is most vulnerable is more heinous. In this analysis of the article researched from the OIG Enforcement Actions website which focuses on defendants accused of fraudulent claims committed to collect on Tess from COVID-19. The details will be presented to address that incident that took place with focus on the False Claims Act being violated and explain how the regulatory bodies of the FBI and the Health and Human Services Office of Inspector General (HHS-OIG) oversaw the prosecution of the accuse parties. The process of information being exchanged on the investigation how offending organization explained of the case, and the outcome will be presented, and justify based on the regulatory laws in place to prevent against such acts in the healthcare sector. “Woman Pleads Guilty to $359M Fraud Involving Claims for Unnecessary Respiratory Tests Submitted with COVID-19 Tests” article was published on the OIG Enforcement Actions website which entailed the incident where California healthcare providers where charges with submitting fraudulent claims to governmental and private insurance programs during the COVID-19 pandemic with medically unnecessary respiratory pathogen panel (RPP) tests that were very expensive and the defendants used the challenging time in healthcare for monetary gains. The article goes on to give details of how providers who worked in a laboratory and collect it Covid, nasal swabs for various locations, such ass, nursing homes system, living facilities, and rehabilitation facilities. The incidence of fraud that occurred worse when the defendants I healthcare fraud scam, collected COVID-19 samples and submitted them for
Running head: Summative Assessment: Fraud and Abuse Enforcement
3
insurance claims for Cova 19, and went further to submit specimens to perform RRP test for the specimens for the collection of additional medical claim reimbursements the target in Medicare population. As the incident was further investigated and re-search it brought forth other claims were the COVID-19 pandemic was targeted by providers to obtain reimbursements from his insurance company, which resulted in over 300 defendants being brought to justice for over $830
million in false claims being reported at the expense of COVID-19 pandemic. This particular incident explained in this article was an example of the False Claims Act being violated. The defendants were investigated and prosecuted and charged with the conspiracy to commit healthcare fraud to which both defendants highlighted in this article played guilty and I said to be
sentenced in January 2024. The False Claims Act (FCA) is a civil statute designed to protect and prevent against fraud and to recover losses resulting from fraud in the Medicaid program as defined by Center for Medicare and Medicaid Services (CMS) and outlined by Author Mosely outlines in Managing legal compliance in the health care industry as he details the FCA violation investigation and prosecution of offenders by the DOJ (Mosley, 2015). While the FCA is a federal government statute there are variations to the law itself in different states but follow the basic elements to prevent fraud claims from healthcare providers. The regulatory bodies that are responsible for the oversight, an investigation of violators of the FCA law is the Justice Department or by private individuals of qui tam proceeding which also is made up of members from governmental bodies such as the FBI or the HHS-OIG in this incident. Author Sherman explains in an article from the OIG website on Federal False Claims Act and details how the act if implemented properly can become a deterrent to the frighten of use committed against Medicare and Medicaid population where he explains how the procedural details of the law
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
Running head: Summative Assessment: Fraud and Abuse Enforcement
4
outline, which fraudulent claims can be prosecuted in a Qui Tam Suit and haul the statue, present
specific details speaking to the civil liability, the offending party or organization can’t be prosecuted based on that act outlines (Sherman, 1977). Though the FCA law has evolved over time since then he continues to play as an advocacy deterrent for the Medicare population being vulnerable is often targeted for fraud at the expense of governmental agencies, such as CMS and Medicaid.
The reporting and communications set in place to report search incidents as fraud can be reported by whistleblowers in the form of patient , organizational employees, or even other providers who find alarm and how claims are processed and reimbursed but it is often called the Special Fraud Alert (SFA), which are often encompassed in the of compliance programs from healthcare organizations. The action of the Qui tam suit is explained how the whistleblower, often referred to as the realtor, presents the sufficient evidence of wrongdoing by healthcare providers, and while being represented by an attorney how is the legal complaint under seal (private) during an investigation and prosecuted by the governmental authorities of the DOJ (Mosley, 2015). The prosecution search offenders, who violate the FCA statute has varying outcomes, most of which were all along the lines of the realtor, being awarded how to 25% of funds recovered, and penalties are assessed based on the severity of the accident and defendants and organization’s responsible with the temporary or permanent disbursement from the participation in the federal health program damage reimbursement and prison punishment for the
perpetrators. In the case of this article where the offending party guilty of conspiracy to commit healthcare fraud will be required to pay damages and face sentences up to 20 years based on the judgment for the governmental body prosecuting. The outcome of this particular case is not uncommon it was explained an article that the offending parties were prosecuted to the fullest
Running head: Summative Assessment: Fraud and Abuse Enforcement
5
extent of the law, the being more favorable for the defendants to plead for the charges they were accused of a significant evidence was presented in the investigation of the false claim charges, which were more impactful because the providers the product mainly the Medicare community during a challenging time and health care due to the COVID-19 pandemic. The Healthcare Fraud
Strike Force program from the Criminal Division’s Fraud Section advises in the week of the final
sentencing of the defendants that they will continue to work the FBI, and the HHS-OIG the final steps to hold you accountable parties before the extent of the law and their involvement of healthcare fraud scheme since it’s enactment in March 2007 as they continue to prosecute offenders, especially ethics, sent a vulnerable healthcare sector during the pandemic. In conclusion of this analysis details of the effects of Fraud and while the egregious fraud claims being reported at the expense of the COVID-19 pandemic were prosecuted to the full extent of the law it is also important for organization to utilizes the governmental and federal
acts and implementing parties are strategically placed with the compliance programs of organization but most importantly governmental agencies are active with audits and enforcement
of policies to ensure the safety and trust of the healthcare population. Reference 1.
Unknown (October 2023)
“Woman Pleads Guilty to $359M Fraud Involving Claims for Unnecessary Respiratory Tests Submitted with COVID-19 Tests” https://www.justice.gov/opa/pr/woman-pleads-guilty-359m-fraud-involving-claims-
unnecessary-respiratory-tests-submitted
Running head: Summative Assessment: Fraud and Abuse Enforcement
6
2.
Moseley III, G. B. (2015). Managing legal compliance in the health care industry. Jones & Bartlett Learning. Chapter 1 and 8. https://bibliu.com/app/#/view/books/9781449639655/epub/OEBPS/12_Chapter_06.html#
page_110
https://bibliu.com/app/#/view/books/9781449639655/epub/OEBPS/07_Chapter_01.html#
page_24
3.
Sherman, P. J. (1977). FEDERAL FALSE CLAIMS ACT - A POTENTIAL DETERRENT TO MEDICAID FRAUD AND ABUSE. Fordham Urban Law Journal
, 5,
493-508. https://www.ojp.gov/ncjrs/virtual-library/abstracts/federal-false-claims-act-
potential-deterrent-medicaid-fraud
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