The False Claims Act Analysis

Health matter, however, when the Act provide poor and/or low-income people with coverage that are as low as it can be with excellent benefits, people abuse it in way that sustain health problem. This result a serious health matter that can turn into a chronic illness or addiction, and cause complicated treatment that could cost a fortune to which is out of the Affordable Care Act coverage line. For example, a female driving a nice and luxury driving down the drive-thru to order her medicine with Medicaid coverage, what will the pharmacist think? Not only is this a fraud, but an abuse of the privilege received through the Affordable Care Act to obtain health insurance at a reasonably low price in order to maintain healthiness. This female have lied and continues to abuse this “authority” and purchase medicine that can worth hundreds of dollar.

The concept of providing basic healthcare services to individuals in need has undergone an agonizing transition, from a luxury once only afforded by the affluent to a basic human right granted to citizens of every economic station, and the recently enacted Affordable Care Act (ACA) was designed to finalize this ethical evolution. Reflecting perhaps the bitter political enmity currently consuming the nation's once cherished democratic process, Republican legislatures in states throughout the union have bristled at the ACA's primary provisions, threatening all manner of procedural protestation as they attempt to delay and derail the bill's eventual implementation. One of the most intriguing aspects of the sprawling, thousand page law, however, has been the stipulation that individual states will be given a choice to either accept federal funding to expand their statewide Medicaid roster, or to forfeit all federal funding for that program in perpetuity. The role of government in monitoring and regulating the healthcare industry has been long debated, and the bitterly contested passage of President Obama's ACA, a law aimed at revising the country's health insurance system through the creating of a federal health insurance exchange to facilitate increased competition among insurers, has rekindled the debate over who holds the ultimate responsibility for regulating the care provided by hospitals, community clinics, and private practices.

Federal or state authorities may investigate allegations of fraud depending on where the fraud was reported, the laws broken, and the amount of money involved. The strictness of penalties levied by state governments varies from state to state. Federal laws such as The False Claims Act, Anti-Kickback Statute, and Social Security Act are laws that address fraud and abuse. Title XI of the Social Security Act contains Medicaid program-related anti-fraud provisions, which impose civil penalties, criminal penalties, and exclusions from federal health care programs on persons who engage in certain types of misconduct (Staman, 2010). Under federal regulations, providers convicted of fraud are excluded for a minimum of five years from receiving funds from any federally

According to the U.S Department of Health and Human Services, the Affordable care Act from President Obama gives consumers more options and benefits when seeking coverage from insurance company. It offers lowering cost as well as gets more access to high quality of care. This law creates Patient’s Bill of Rights that is very effective to protect consumers from any abuses or fraud from insurance company. Some preventive services are available to many Americans especially Medicare recipients at no cost. Not just that, they also receive a special offer of 50 percent discount for any well-known drugs in the market place under Medicare named “donut hole.” The Affordable Care Act helps other organizations and programs to convince healthcare providers

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

Medicare and Medicaid have cause a great deal of damage to the American society. "Years of scandal have shown the waste, fraud and abuse that is rampant in Medicare and Medicaid." (Fallen Guardians of Justice: How the Supreme Court is

Health care fraud and abuse is a significant contributor to high health care spending, resulting in the wasteful spending of health care dollars. The Federal Bureau of Investigation (FBI) and National Health Care Anti-Fraud Association (NHCAA) estimates that 3 to 10 percent of health care dollars are lost to fraud and abuse (Federal Bureau of Investigation, 2010). Fraud is the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the deception could result in some unauthorized benefit to themselves or some other person (Ryan, 2006). Bloomberg reports health care expenditures are rising faster than the rate of inflation and spending in the US has nearly doubled in the last decade and one-half of health care

n Baltimore, Maryland theSt. Agnes Healthcarehad False Claims Act alleging that they submitted false claims to Medicare by billing for evaluation and management services at a higher reimbursement rate than the Federal healthcare programs allowed. They agreed to pay the United States $122,928 to resolve the claims under the False Claims Act. In June 2011, St. Agnes acquired a medical practice consisting of twelve cardiologists who were formerly members of MidAtlantic Cardiovascular Associates. The twelve cardiologists became employees of St. Agnes and continued to provide services to their patients through Maryland Cardiovascular Specialists, a specialty practice affiliated with St. Agnes. Medicare permits a higher rateof reimbursement

The federal Anti-Kickback Statute is a criminal statute that prohibits the exchange (or offer to exchange), of anything of value, in an effort to induce (or reward) the referral of federal health care program.  In return for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under a Federal health care program. For the mens rea requirement the defendant must “knowingly and willfully” solicit, receive, or pays any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly in cash or in kind to induce such person…to purchase, lease, order, or arrange for or recommend purchasing…or

Some federal statutes address fraud in government health care programs, and many of these laws vary considerably (Krause 2004). Some of these laws specifically target health care fraud. Example of the laws that the government direct at inappropriate health care activities includes the “Medicare and Medicaid Anti-Kickback Statute and Ethics in Patient Referrals Act (EPRA).”

According to the Federal Bureau of Investigation (FBI) “health care fraud costs the country an estimated $80 billion dollars a year” ("Health Care Fraud," n.d., p. 1). Because health care costs continue to rise more rapidly than the rate of inflation the threat of health care fraud continues to rise. The Affordable Health Care Act has put new policies in place to identify and stop health care fraud. The FBI along with other government, insurance, and public agencies have joined together to combat fraud at every level. New rules in identifying, investigating, and prosecuting fraud before payments are made to medical providers could save billions of

Collectively, the Department of Health and Human Services and the Department of Justice work to reduce healthcare fraud and investigate dishonest providers and suppliers. The Health Care Fraud Prevention and Enforcement Action Team recouped almost 3 billion in fraud, this year alone. Also, aggressive strategies exist to eliminate Medicare prescription fraud. Patients abusing or selling painkillers received by visiting several doctors and obtaining multiple prescriptions costs Medicare millions annually. Fraud affects everyone, preventing it requires government officials and citizens diligently working together.

Healthcare services have been on the rise for over 10 years now. According to a 2012 consumer alert, the industry provided $2.26 trillion in payments for more than four billion health insurance benefit claims in the year 2011(Fraud in Health Care). The bulk of the claims and the mainstream of fraud and abuse stem from the Medicare system professionals, who are knowledgeable about the process and persuade new clients into handing over their pertinent information in hopes of deception and illegitimate claims. Multiple and double billing, fraudulent prescriptions, are some of the major flaws in this organization that has made the healthcare services industry curdle. (AGHAEGBUNA, 2011) This is a non-violet crime and is often committed by very

Although Congress has used several anti-fraud measures to protect the federal government health care programs, the False Claims Act of 1986 has become the main weapon that government prosecutors use against perpetrators of health care fraud. Designed to prevent fraud and other abuses in federal government programs, the False Claims Act has been the primary statute the government has used in its fight against health care fraud. However, government prosecutors do not rely on one statute in their prosecution of alleged cases of health care fraud. Instead, they rely on a combination of statutes, but the False Claims Act has emerged as the main statutory weapon.

Insurance companies and the federal government should pool resources using a percentage of profits to finance a task force to arrestively fight fraud. The penalty for fraud should be more stringent which will cause perpetrators to think twice before formulating a plan to commit fraud. The Affordable Health Care Act is the beginning of many programs established to fight against fraud. Health care fraud is a growing problem and should be taken more seriously by citizens of the United States. Physicians, health care workers, and patients are responsible for