The Federal Anti-Kickback Statue Analysis

“Medical malpractice occurs when a hospital, doctor or other health care professional, through a negligent act or omission, causes an injury to a patient. The negligence might be the result of errors in diagnosis, treatment, aftercare or health management.” (Admin) One of the most common type of claims that pharmacies face are negligence claims. Negligence is one of the categories that falls under the area of law called Torts. In the Hundley v Rite Aid case, a tort was filed for injuries that were sustained by Gabrielle Hundley after she took medication from an incorrectly filed prescription. The case involved a jury trial verdict involving Gabrielle Hundley, a minor child, against Howard Jones, the pharmacist, and the Rite

Medicaid fraud comes in many forms. A provider who bills Medicaid for services that he or she does not provide is committing fraud. Overstating the level of care provided to patients and altering patient records to conceal the deception is fraud. Recipients also commit fraud by failing to report or misrepresenting income, household members, residence, or private health insurance. Facilities have also been known to commit Medicaid fraud through false billing. The Medicare and Medicaid fraud and abuse statute provides that an individual who knowingly and willfully offers, pays, solicits, or receives any remuneration in exchange for referring an individual for the furnishing of any item or service

Covered entities should always ensure they are adhering to all federal, state, and local laws. Covered entities contracting with pharmacies to dispense 340B drugs should be aware of the federal anti-kickback statute and the way in which such requirements could apply to their arrangements with contract pharmacies. Cases of suspected violations of the anti-kickback statute should be directly referred to the Office of the Inspector General (OIG) who oversees this provision. The OIG can be reached at: Online:http://oig.hhs.gov/fraud/report-fraud/report-fraud-form.aspx Phone: 1-800-HHS-TIPS (1-800-447-8477) Fax: 1-800-223-8164

While in the chair I mentioned to the doctor I required a prescription for an abscess. Dr. “I didn't give you one” “No” was my reply. The assistant called it in. Received my “Explanation of Benefits” and there was a charge of $65. I telephoned the practice and they stated that the charge was for calling the prescription into the pharmacy. For Calling The Prescription Into The Pharmacy. What Audacity!

Medicare part D is the prescription drug plan. Each plan has its own list of covered drugs (called a formulary). Many Medicare drug plans place drugs into different tiers on their formularies. Drugs in each tier have a different cost. For example, a drug in a lower tier will generally cost less than a drug in a higher tier. In some cases, if the drug is on a higher tier and the patient 's prescriber (the patient 's doctor or other health care provider who is legally allowed to write prescriptions) thinks the patient needs that drug instead of a comparable drug on a lower tier, the prescriber can ask the patients plan for an allowance to get a lower copayment. In the case of Mrs. Zwick Part D will cover the prescription drugs that she needs that are not covered by Medicare Part A and Part B unless those medications are on the unapproved list. What the patient will be responsible for paying

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

Many Medicare patients are turned away because they lack the ability to pay the doctor for his or her services. Instead of treating the patient, the doctor may hand them a referral slip,

In conclusion, given that due to lack of better judgement throughout all the Rite Aid chain store within the nation many of the policies had to be rewritten based on pill bottles being disposed with patient’s personal information listed on them. Due to those actions it has brought into investigation by several agencies such as HHS Office of Civil Rights (OCR) and FTC which will focus on questioning the laws broken regarding HIPAA laws that was violated. Consequently, following the entire investigation it was found that Rite Aid was held liable under the HIPAA privacy act for improperly disregarding patients pill bottles in the public garbage. The ending result of this case has found Rite Aid at fault and they agreed to pay a settlement in the

The passage of the Medicare Drug Price Negotiation Act will also inadvertently increase access to many types of medications for individuals who qualify for Medicare Part D. There is a clause within the bill that would establish rebates to be paid by pharmaceutical companies for low-income beneficiaries. These rebates, in addition to lowered costs, would considerably lessen the financial burden placed on low-income beneficiaries. This will allow more individuals greater access to expensive medications. As an example, each year, financial reasons hinder about 16% of diabetic Part D beneficiaries from filling at least one of their prescriptions (Williams, Steers, Ettner, Mangione, & Duru, 2013). This increase in access will help mitigate the occurrence of cost-related nonadherence to prescription medications, and other such consequences

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.

Fraudulent prescriptions are also on the rise. Physicians are writing illegal prescriptions that are billed for a claim for reimbursement, but have yet to see a bill of rendered services that called for the actual prescription. This often ends up happening to a patient who has little or no medical issues and has never been seen before. The provider who receives the forged prescription profits an anticipated amount of 15% to $20% in profits. (AGHAEGBUNA ,2011). There are four types of fraud that healthcare providers’ organization face. Patient fraud, provider employee fraud, provider billing fraud and payer fraud, even though providers need to receive payment for their service they should be more preventative action in place to ensure that these fraudulent activities can be detected.

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.

As the healthcare industry begins to expand its horizons, by featuring more staff and patients, the types of frauds that are committed also rise in number and complexity. One of the many consequences that derives from fraud within the healthcare system includes an increase in the cost of healthcare itself. In order to limit and analyze fraud that encompasses the entirety of the healthcare industry, it is necessary to assess the different types of frauds and in doing so also understand the method of reimbursement involving the professionals and members of the health care industry. Since a majority of these reimbursements are paid by insurances or through government programs, a program known as coding was created in order to organize and properly pay off these reimbursements(Marilyn Price, Donna Norris, 2009). One of the many