District Court Case: The False Claims Act

What is the control mechanism the government uses on Medicare payments to physicians, and how is it applied?

There is a document for diagnostic laboratory testing that the centers for Medicare and Medicaid (CMS) policies with the respect to the circumstances under which laboratory tests are considered reasonable and necessary, and not screening for Medicare purposes is called National Coverage Determinations (NCDs). A Medicare assignment was accepted by Regional Pathology Services and is not allowed to bill Medicare beneficiary for the NCD tests listed below unless the ABN is executed by the provider that tells the beneficiary in advance of the service that they will be responsible for the payment of the test if the Medicare should deny payment.

The pharmacist submitted claims for reimbursement on brand name medications rather than on the less expensive generic drugs that were actually dispensed. This is a result of health care fraud on Medicare part D, which is in violation of the False Claims Acts (FCA) and anti-kickback statues. "The FCA protects the government from being overcharged or sold substandard goods or services" (CMS, 2015). The federal Anti-Kickback Statue is designed to protect patients and federal health care programs from fraud and abuse. It states "that anyone knowingly and willfully offer, pay, solicit, or receive any remuneration directly or indirectly to induce or reward referrals of items or services reimbursable by a Federal health care program" (CMS, 2015)."The

Under the qui tam and provisions of the False Claims Act, The lawsuits were filed by Dr. Michael Mayes and other three whistleblowers. Also, two of the lawsuits separately were against the previous CEO Phillipe Goix of Berkeley as responsible for the scheme.

• A laboratory cannot bill a Medicare Beneficiary for a laboratory test unless it notifies the patient in writing that Medicare is not going to pay for the test

Permits private parties to file qui tam actions claiming that defendants defrauded the government (False Claims Act Overview, 2016).

The Indian Claims Commission Act is a number of incredible legal sections that reflect the problems that have come to pass between the United States and various Indian tribes. The suits in accordance with the Act led in turn to certain procedures and aspects of special interests to the government. The Act was approved on August 13, 1946 and was to prevail for ten years, all the claims that were submitted had to be filed within five years from the approval date. Since there were a large number of claims that had not been heard, the Act was extended in all its details until 1962.

Attempts to stop fraud were enhanced under Public Law 104-191, the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The purpose was to improve the Medicare program under title XVIII of the Social Security Act, the Medicaid program under title XIX of such Act, and the efficiency and effectiveness of the health care system. This public law encouraged the development of a health information system through standards and requirements for the electronic transmission of certain health information (aspe.hhs.go). The Act established a program to take action against fraud committed against public and private health plans. The legislation required the establishment of a national Health Care Fraud and Abuse Control Program (HCFAC), under the joint direction of the Attorney General and the Secretary of the Department of Health and Human Services (HHS) acting through the Department 's Inspector General (HHS.gov). The HCFAC program is designed to coordinate Federal, State and local law enforcement activities with respect to health care fraud and abuse. The Act requires HHS and Department of Justice (DOJ) detail in an Annual Report the amounts deposited and appropriated to the Medicare Trust Fund, and the source of such deposits. (HHS.gov) I will summarize the impact of these laws as it pertains to how they are impacting the healthcare delivery system. (HHS.gov)

If I had suspicions of a doctor wanting me to file false claims. I would research the cases where the pattern seemed to appear or happened to look for supporting documetion for the service that are being claimed. After doing some checking into them if I still felt that something was wrong, I would have to report my concerns. I wouldn’t file a claim that I had doubts about or thought were an inflated claim. Not reporting my concerns would make me just as guilty as the doctor and I could be charged with at least a misdemeanor plus fines. Most insurance companies have ways to report suspicion of abuse or fraud anonymously. Would report anonymously out of fear to tell the truth, but I would also include supporting documetion to help them investigate

Each company is an independent auditing company and paid only for each improper payment recovered. The process used to determine if a claim is inaccurate is the use of algorithm data which is an automated review of the payment paid to the provider. RAC uses the same methods as FI and MAC carriers to identify an overpayment or underpayment of a provider. When RAC identifies an anomaly in the provider’s record they must get approval from the CMS to issue a letter demanding reimbursement of payment for being overpaid. Once an overpayment is discovered and a letter of demand is sent the provider has a certain amount of time to refute the findings (Casto, Anne, and Elizabeth Forrestal, Fourth Edition, 4th Edition. AHIMA Press,).

The Constitution of the United States has the amendments in place to protect the citizens from the violation of his or her rights by the government. The Federal Tort Claim Act of 1946 is enacted to ensure the citizens of the United States will receive the proper compensation or if the citizens want to sue the federal government. The Federal Tort Claim Act of 1946 will provide the citizens of the United States enough cushion to go around the immunity for federal employees. Before the enactment of the Federal Tort Claim Act of 1946, the citizens would have no possible way of suing the federal government for wrongdoing. It allows federal employees the

This article discusses how Medicare Carriers and Fiscal Intermediaries use coverage determinations to establish medical necessity. When the condition(s) of a patient are expected to not meet medical necessity requirements for a test, procedure, or service, the provider has the obligation under the Beneficiary Notices Initiative to alert the Medicare beneficiary prior to rendering the service. The Medicare beneficiary is notified via the Advance Beneficiary Notice (ABN) (see page 235 in Appendix B).

Common fraudulent practices include billing for services never received, upcoding or unbundling of services, and mislabeling. Billing dishonest services occurs anytime a healthcare provider charges Medicare for a service the patient never received or billing for a more expensive service than performed. Upcoding and unbundling, two examples of billing for a more expensive service demonstrate this fraudulent practice. Simply put, upcoding occurs by billing more expensive codes than the services performed, while unbundling refers to a “bundled” service broken down or unbundled, allowing procedures billed separately to obtain a higher reimbursement than customary. Mislabeling, the practice of substituting non-covered services or products with services or products covered under Medicare guidelines also constitutes fraud. For example, a home healthcare company commits fraud by mislabeling house cleaning services, not covered by Medicare, as a nurse visit in order to receive payment. A pharmacy filling a patient’s prescription with generic drugs and charging for name brand drugs also represents mislabeling.

A 2009 article reported the Medicare/Medicaid fraud is litigated by federal authorities ensuring the severity of such billing fraud has substantial repercussions (Gasquoine & Jordan, 2009). The

When it comes to abuse it can involve an action of consistent with any accepted, in medical, business, or fiscal practices. This can also be an abuse directly that can unnecessary affect the cost to any programs through improper payments. The difference between fraud and abuse is the person’s intentions. I do believe it can be abuse because no matter what insurance they have if there coming in to see the doctor they are there to receive the same services as any other person that have Medicare. As the office manager I will discuss the issue to the physician about the matter on why a Medicare patient has more lab then a non-Medicare patient. But before asking any questions I will look in to the patient chart to check if there labs are not being