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Pozgar - Ch 4 - Criminal Aspects of Health


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Objectives of Criminal Law

Maintain public order and safety
Protect individuals
Use punishment as a deterrent to crime
Rehabilitate criminals for return to society
A social harm defined and made punishable by law
A crime punishable by less than 1 year in jail or a fine
A crime punishable by imprisonment in a state or federal prison for more than 1 year
Examples of Health Care crimes
false claims
unethical referrals
falsification of records
misuse and theft of drugs
patient abuse
criminal negligence
petty theft
sexual abuse
an unlawful act, generally deception for personal gain
The return of part of a sum received because of a confidential agreement
false claims
knowingly presenting, or causing to be presented, to the government a claim for payment that
is in error (usually for excessive reimbursement)
unethical referrals
a payment made by one party to another in order to induce the payee to send business to the
falsification of records
includes clinical documentation that supports care that was not rendered or care that was
rendered at a lower level than what is documented as well as omissions of documentation
criminal negligence
recklessly acting without reasonable caution and putting another person at risk of injury or
death (or failing to do something with the same consequences)
intentional killing of a person.
petty theft
taking property valued at less than some statutorily predetermined amount; in Florida theft at
less than $300 is considered petty; misdemeanor
sexual abuse
any sexual act without consent.
False Claims Act of 1986
Prohibits knowingly presenting or causing to be presented to the government a false claim for
patient abuse
mistreatment or neglect of persons under the care of a health care organization
forms of patient abuse
other harm
elements that establish a crime has been committed
actus reus
mens rea
attendant circumstances
actus reus
"The Guilty Act" this term refers to an act prohibited by law
mens rea
The "guilty mind" necessary to establish criminal responsibility.
attendant circumstances
a "circumstance" connected to an act, an intent, and/or a result required to make an act
criminal; the facts surrounding an event
Medicare and Medicaid Patient Protection Act of 1987
42 U.S.C. §1320a-7b
(the "Antikickback Statute"), provides for criminal penalties for certain acts impacting
and state health care (e.g., Medicaid) reimbursable services. Enforcement actions have
in principals being liable for the acts of their agents. Of primary concern is the section of the
statute which prohibits the offer or receipt of certain remuneration in return for referrals for
recommending purchase of supplies and services
reimbursable under government health care
Ethics in Patient Referral Act of 1989
Section 1877 of the Social Security Act (the Act) (42 U.S.C. 1395nn), also known as the
physician self-referral law and commonly referred to as the "Stark Law":

Prohibits a physician from making referrals for certain designated health services (DHS)
payable by Medicare to an entity with which he or she (or an immediate family member) has
a financial relationship (ownership, investment, or compensation), unless an exception
Prohibits the entity from presenting or causing to be presented claims to Medicare (or billing
another individual, entity, or third party payer) for those referred services.
Establishes a number of specific exceptions and grants the Secretary the authority to create
regulatory exceptions for financial relationships that do not pose a risk of program or patient
Medicare Exclusion List
A searchable, online database of individuals who have been barred from receiving payments
for services to Medicare and Medicaid patients
Corporate Integrity Agreement
An agreement that a health care provider or health plan reaches with the OIG of the DHHS as
part of a settlement agreement when allegations of improper reimbursement have been made.

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Legally Speaking
My philosophical and analytical take on various ethical topics.

Thursday, April 14, 2016

Medical Fraud/Criminal Aspects in Health Care

Hello all, today I will be writing about health care fraud in
the United States. Health care fraud is a serious crime
that affects everyone. The National Healthcare Anti-
Fraud Association estimates that the financial losses in
the United States due to health care fraud is around ten
billion dollars a year. Health care fraud also results in
people paying a higher premium for health insurance
and out-of-pocket expenses. Unfortunately, financial
losses are not the only consequence of health care
fraud. Another consequence of health care fraud is
unnecessary and potentially dangerous medical
procedures that risk the lives of the patients involved.
Health care fraud, like all other categories of fraud, relies
on false information. There are countless of news
articles you can read about fraud being conducted by
dishonest medical professionals. Whether it is a
physician falsely diagnosing patients with cancer to
profit off of expensive cancer drugs, or psychiatrists
falsely claiming that their patients are psychotic and
suicidal then billing them expensive and dangerous
medication that they don't need. For example, there is
an article from CNN about medical fraud conducted by
Dr. Farid Fata in Detroit, Michigan. Dr. Fata pleaded
guilty to giving cancer treatments to misdiagnosed
patients, telling some of them that they had a terminal
cancer. Dr. Fata pleaded guilty to 13 counts of Medicare
fraud, one count of conspiracy to pay or receive
kickbacks and two counts of money laundering and will
be serving 45 years in priston. Dr. Fata collected a little
over 17 million dollars from Medicare and private
insurance companies.

In response to the growing concern of health care fraud,

The United States passed the Health Insurance
Portability and Accountability Act of 1996 (HIPAA),
which specifically established health care fraud as a
federal criminal offense and carries a prison term of up
to 10 years in addition to financial penalties.

The National Health Care Anti-Fraud Association

(NHCAA) recommends the following as ways you can
individually protect yourself from health care fraud:
 Protect your health insurance card like you would
protect your bank card and social security card.
 Be careful about disclosing your insurance
information. Do not give your insurance information
to door to door or phone solicitors, and avoid putting
your information over the internet.

 Be informed about the healthcare you receive, keep

good records of your medical care, and review all
the medical bills you receive.

 Be aware of free offers. Most offers of free

healthcare services, tests, or treatments are often
fraudulent schemes designed to bill you and your
insurance company illegally.

Thank you all for reading my blog on medical fraud!
Posted by George Biko at 6:28 PM
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1 comment:

Rosario HitchDecember 6, 2017 at 4:27 AM

Clean, quick clinic with great staff great resource. Reasonably priced, even cheaper when you
check in. My husband was in and out in less than 30 minutes. click here

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1. Small Business»
2. Business & Workplace Regulations»
3. Workplace Safety»

How to Handle Ethical Issues in the Workplace

by Ruth Mayhew

The cautious handling of workplace ethics issues can resolve personal and business dilemmas.

Hemera Technologies/ Images

Related Articles

 1 How to Resolve Ethical Dilemmas in the Workplace

 2 Common Ethical Workplace Dilemmas
 3 What Are the Major Ethical Issues Business People Face?
 4 List of Ethical Issues in Business
Morality and values-based dilemmas in the workplace are, at best, difficult to handle when employees have to choose
between what’s right and what’s wrong according to their own principles. Forward-thinking employers who implement
workplace ethics policies are usually well-prepared for the potential conflicts of interest that arise due to the diversity of
opinion, values and culture in the workforce. However, handling ethical issues in the workplace requires a steady and
cautious approach to matters which can potentially be dangerous or illegal.

1. Develop a workplace policy based on your company’s philosophy, mission statement and code of conduct. Incorporate the
policy into your performance management program to hold employees accountable for their actions and alert them to their
responsibilities to uphold professional standards throughout their job performance and interaction with peers and
supervisors. Revise your employee handbook to include the policy and provide copies of the revised handbook to employees.
Obtain signed acknowledgement forms from employees that indicate they received and understand the workplace ethics

2. Provide workplace ethics training to employees. Utilize varied instruction methods to engage employees in learning how
to address and resolve ethical dilemmas. Experiential learning, or role-play, is an effective way to facilitate workplace ethics
training. Examples of workplace ethics simulations involve scenarios about the misappropriation of company funds, personal
values related to improper workplace relationships and the organization’s compliance with regulatory controls.

3. Designate an ombudsperson in charge of handling employees’ informal concerns pertaining to workplace ethics. Consider
whether your organization also needs an ethics hotline, which is a confidential service employees may contact whenever
they encounter workplace dilemmas that put them into uncomfortable or threatening positions. Confidential hotlines are an
effective way to assure employees’ anonymity, which is a concern for employees whose alerts are considered
“whistleblowing” actions.

4. Research federal, state and municipal labor and employment laws pertaining to whistleblowing. Refrain from making
employment decisions, such as termination or suspension, in connection with whistleblowing or an employee’s right to
protected activity under whistleblowing laws or public policy. Seek legal advice for employee reports of workplace ethics
issues that increase your organization’s liability under federal, state or municipal employment law. Under the Texas
Whistleblower Act, for example, public-sector employees may be entitled to damages if an employer engages in retaliatory
actions based on an employee who, in good faith, files a complaint related to workplace ethics. The Act grants "[a] public
employee who claims that his suspension, termination, or other adverse personnel action was in retaliation for his good faith
reporting of violations of the law the right to sue for damages and other relief."

5. Apply your workplace policy consistently when addressing workplace issues and employee concerns about workplace
ethics. Use the same business principles in every circumstance, regardless of the perceived seriousness or the level of
employees involved. Communicate the same expectations for all employees – whether they are in executive positions or
front-line production roles – and approach every issue with equal interpretation of the company policy.

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References (5)

Resources (3)

About the Author

Ruth Mayhew has been writing since the mid-1980s, and she has been an HR subject matter expert since 1995. Her work
appears in "The Multi-Generational Workforce in the Health Care Industry," and she has been cited in numerous
publications, including journals and textbooks that focus on human resources management practices. She holds a Master of
Arts in sociology from the University of Missouri-Kansas City. Ruth resides in the nation's capital, Washington, D.C.
Photo Credits

 Hemera Technologies/ Images

Suggest an Article Correction

More Articles

[Ethical Issues] | Examples of Ethical Issues in Business

[Ethical Issues Within Organizations] | Common Types of Ethical Issues Within Organizations

[Business Ethics] | Examples of Business Ethics in the Workplace

[Conflicts] | Ethical Conflicts in the Workplace

Also Viewed

 [Importance] | The Importance of Ethics in Organizations

 [General Business Community] | Top Ethical Issues Facing the General Business Community
 [Issues HR Managers Face] | Ethical Issues HR Managers Face in an Organization's Culture
 [Workplace Ethics] | Workplace Ethics & Behavior
 [Ways] | Ways to Prevent Unethical Behavior in the Workplace
 [Dilemma] | What Causes an Ethical Dilemma in Conducting Business?
 [Examples] | Examples of Unethical Behavior in the Workplace
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As a member of a board or management committee you have fiduciary obligations to your


In legal terms, this means —

you have a very strong obligation of loyalty to your organisation

you must not get any unauthorised benefit (profit) from your position, even unintentionally; and

you have a primary duty to your organisation — this means

you must not place your own interests ahead of the interests of your organisation (avoid conflicts of
interest and duty);
you must not place your duty to anyone else ahead of your duty to your organisation (avoid conflicts
of duty and duty).

To avoid these problems and conflicts, no board or management committee member should take
part in decisions in which he or she has an interest. This is reinforced in most Australian jurisdictions
by the relevant legislation, and penalties can be imposed for breaches of the legislation. There can
also be an action for a civil remedy if an organisation suffers a loss because of breach of fiduciary
duty. For example, a board member found to be in breach may have to pay compensation for loss,
or pay over any unauthorised profit, to the organisation.

A conflict of interest policy will help by —

formalising the process by which board and senior management identify and notify potential

giving clear guidance about what should be done when any board member has an interest in a board
decision; and

outlining the process to be followed when a board member participates in a decision in which he or
she is not disinterested.

See more on conflicts of interest in our pages on board policies

— Conflict of interest policy

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