Question

Health care fraud is a form of white collar crime. It involves filing illegitimate health care claims to turn an illicit profit. The 3 major laws that protect against healthcare fraud are the Anti-kickback statute, Stark, and the False Claims Act. find one (1) specific real life legal case example of how kickback arrangements would violate the Stark Law. In addition, discuss how the kickback arrangements could violate trust between provider organizations and patients. find one (1) specific real life legal case example of a breach of the False Claims Act by a health-related organization. In addition, discuss whether health care organizations are properly equipped to ensure compliance and minimize exposure risks. If not why not?

Answer 1

Anti-kickback statute Stark Law:

The Physician Self-Referral Law, often called the Stark Law, prohibits a physician from referring certain designated health services payable by Medicare or Medicaid to an entity in which the physician (or an immediate family member) has an ownership/investment interest or with which he or she has a compensation arrangement, unless an exception applies (CMS 2017). While the Stark Act prevents a physician’s financial interests from influencing the typeand quality of care that patients receive, The Anti-Kickback Act reinforces the policies underlying the Stark Act through criminal sanctions. According to CMS (2017), Penalties for physicians who violate the Stark Law may include fines for each service, repayment of claims, and potential exclusion from all Federal health care programs. The federal governmentinterprets the term “financial relationship” broadly to include any direct or indirect ownership or investment interest by the referring physician, as well as any financial interests held by anyof the physician’s immediate family members (Staff, n.d). Stark Law violations can result in penalties of up to $15,000 for each billed service that is based on a prohibited referral, plus three times the amount of the government overpayment .

An example of a Legal case:Christiana Care Health System in Wilmington, Delaware, has agreed to pay $3.3 million to settle claims made by a whistleblower that the health system allegedly paid kickback to neurologists for referring patients to its Wilmington hospital. The whistleblowers in the lawsuit were a group of physicians from a competing neurology group and they receive $190,000 in the settlement, according to the report.