medical law_Module 05 Assignment - Fraud and Abuse Laws_031024

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HIM2410 Module 05 Assignment – Fraud and Abuse Laws 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. Action: Healogics, Inc.'s actions were fraudulent State Law/Rule: This action violates the False Claims Act (FCA), which states that anyone who knowingly submits or causes the submission of false claims to the government is responsible for paying three times the amount of damages incurred by the government in addition to a penalty that is adjusted for inflation. Reasoning: Healogics.Inc intentionally led wound care centers to invoice Medicare for treatments that were not medically necessary or to submit false claims to Medicare for HBO therapy that was not medically necessary or permitted. 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.
HIM2410 Module 05 Assignment – Fraud and Abuse Laws Action: 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") were fraudulent . State Law/Rule: This action violates the False Claims Act (FCA), which states that anyone who knowingly submits or causes the submission of false claims to the government is responsible for paying three times the amount of damages incurred by the government in addition to a penalty that is adjusted for inflation. Anti Kickback Law : This statute criminalizes the act of offering or receiving kickbacks, bonuses, commissions, rebates, or engaging in split-fee arrangements in exchange for referring patients or patronage to or from a healthcare provider or facility. It applies to all individuals, including healthcare providers and facilities. Reasoning: Health Quest submitted claims for evaluation and management services. However, the documentation provided did not justify the level of service claimed. Consequently, the services were charged at a level that exceeded what was supported by the medical record. Health Quest submitted claims for home health services without adequate medical documents to substantiate the claim, including documentation of a face-to-face meeting with a physician. The hospital subsidiary of Health Quest, PHC, is accused of submitting potentially fraudulent inpatient and outpatient care claims. Two orthopedic specialists supposedly referred these services to PHC. The two physicians had a direct financial affiliation with PHC to provide administrative services and earned remuneration from PHC. 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. Action: The coder at Livewell Medical Center's actions were not fraudulent State Law/Rule: None Reasoning: The coder refused to give in to their manager's request and persisted in upholding the integrity of the codes. 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
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