Healthcare Abuse and Fraud: Prosecution, Protection and Prevention - Essay Sample

Published: 2023-11-24
Healthcare Abuse and Fraud: Prosecution, Protection and Prevention - Essay Sample
Type of paper:  Essay
Categories:  Law Medicine Healthcare
Pages: 4
Wordcount: 1005 words
9 min read


Healthy and Safety is the subject of many laws and regulations, failure to adherence to the law renders health facilities and persons liable to prosecution. Health and Safety are essential because it protects the wellbeing of patients and health workers. Looking after health makes good business sense. In light of this, eradicating healthcare abuse and fraud has become top precedence for the federal government in the United States of America. Government investigations are on the climb, and health facilities in the U.S are trembling at the thought of becoming the next investigative target. To ensure fewer cases of inaccurate or incomplete registration and eligibility verification, prior authorization and pre-certification issues, missing or invalid claims, multidisciplinary data teams have been auditing health facilities. Under the Affordable Act, any health centre a member of Medicare program have to adhere to compliance programs (Sale, & Weintraub, 2010). The purpose of this paper is to analyze the health facilities that were audited to determine whether it is compliance or not to pass judgment

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How Renting Imagining Equipment violates Compliance Law

The act of renting imagining equipment from staff radiologists, which is located in the radiologist is private, off-campus, office according to the compliance program is unlawful to act and has a severe consequence. Therefore, the radiologist is guilty of breaking the Stark Law, also known as the Physician Self-Referral Law. Wales (2003) defined the Stark Law is a set of laws, which make it unlawful for health providers to refer patients to themselves. In other words, the law bans making a referral to specifically designated health service payable by Medicare by a physician. The director could not be found guilty under the same rule if it was not renting the imaging equipment. The Stark Law permits referral if can it can be demonstrated that financial interest is an exception. Other exceptions are linked to just investment and ownership. The fact that the physician act does not fall under any of the exception consideration is prone to face either one of the judgment. Denial payment, face significant civil penalties for violating the Stark Law and can chance to lose their right to bill Medicaid.

Breaching of Legal Duty by the Director

A medical director has a legal duty to oversee a service or program to advance a clinical agenda. The key responsibilities of a medical director comprise policy development, clinical oversight, quality review, staff training, regulatory adherence, committee participation. Above all, the physician works with leadership to represent the hospital. From the case study, one can there assume that the director collaborated with the doctor to renting of imaging equipment in his office. Thus, Sale and Weintraub (2010) assert that under the anti-Kickback Statute (AKS), the directors have breached his duty to overview services.

Example of such criminal case of United States V. Borrasi further strengthens claims were medical directors payments can result in criminal liability under the federal anti-kickback statute. The case a director was sentenced under the Anti-kickback Statute for collaborating to receive bribes from a nursing home for referring patients to the facility.

Importance of Self-report

According to the article by Toffel and Short (2011) claim that voluntarily report violations of the Stark Law can lead to settlements that are of smaller penalties than penalties in an enforcement action. Hence, when the facilities choose to do self-reporting, it stands to benefit from the following.

First, self-reports suggest that the supplier or provider has a strong and effective compliance program. Consequently, it may minimize the probability that the Office of Inspector General (OIG) will need a corporate integrity contract in exchange for a release from the prohibition from Federal healthcare programs.

Second, self-reporting typically prolongs the deadline set under section 6402 of the ACA for reporting and returning overpayments. Usually, that cutoff date is the later of the date that is three months after the date on which the overpayment was noted. Or the date any parallel cost report is unpaid, if applicable (Leininger, 2011). By self-reporting under the SRDP, nonetheless, the commitment to return the identified overpayment is postponed until a settlement arrangement is attained, the supplier extracts its confession under the SRDP or CMS eliminate the supplier from the SRDP.

Finally, a voluntary confession can frequent prevent private parties from presenting False Claims Act lawsuits. While a party can give report to CMS, whereas a government investigation already targets it, the self-reporting must be submitted in good faith. If the confession is tabled to bar an existing inquiry, CMS will eliminate the self-report party from the procedure. To assist gauging a self-reporting party’s good faith, the SRDP needs that party to state whether it has any information regarding the matter is under current investigation by a government contractor.

In conclusion, organization self-report is a crucial process that can prevent negligence since doctors are permitted to assess their performance and notecases that need improvement. Therefore, organization self-report is an act, which can curb the occurrence of penalties, which are executed by OIG due to non-compliance instances. Organization Stark violators through self- disclosure program can save their healthcare firm substantial amounts of money.


Leininger, P. (2011). All Deliberate Speed-CMS Creates More Uncertainty by Invoking the Infamous Civil Rights Standard in Proposed Rule on Overpayments. Health Law., 24, 24.

Sale, J. A., & Weintraub, B. (2010). Emerging Trends in Criminal Healthcare Law Enforcement: The Patient Protection and Affordable Care Act of 2010 Reduces the Criminal Mens Rea Requirement for Healthcare Fraud and Increases Penalties under the Federal Sentencing Guidelines. Health Law., 23, 20.

Toffel, M. W., & Short, J. L. (2011). Coming clean and cleaning up: Does voluntary self-reporting indicate effective self-policing?. The Journal of Law and Economics, 54(3), 609-649.

US v. Borrasi, 639 F.3d 774 (7th Cir. 2011).

Wales, S. D. (2003). The Stark Law: Boon or Boondoggle-An Analysis of the Prohibition on Physician Self-Referrals. Law & Psychol. Rev., 27, 1.

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