The Federal Anti-Kickback Statute (42 U.S.C. 1320a-7(b)) restricts suppliers of goods or services secured by a government healthcare program ("Federal Healthcare Program") from intentionally and readily requesting or accepting or giving any compensation, directly or indirectly, in trade or in kind, to actuate either the referral of an individual, or outfitting or orchestrating a good or service for which imbursement may be made under a Federal Healthcare Program. The Federal Anti-Kickback Statute is a goal based statute.
Certain dealings and engagements are statutorily absolved from the Federal Anti-Kickback Statute (e.g., remuneration paid in accordance with a legitimate employment relationship). Furthermore, dealings and engagements that go along completely with established Safe Harbor regulations shall not be arraigned under the Federal Anti-Kickback Statute. Essentially, notwithstanding, a transaction or engagement that does not meet all the necessities of a Safe Harbor regulation is not fundamentally illicit.
The Federal Anti-Kickback Statute is a criminal statute and the punishments for infringement of the law can be serious. They incorporate fines of up to $25,000 for every infringement, crime conviction deserving of detainment up to five years, or both, and in addition conceivable avoidance from cooperation in Federal Healthcare Programs.
Discussion
Fraud is defined as a deliberate dishonesty or distortion committed by an individual, that effects in some unlawful gain to him/herself or to someone else. According to research, the health care industry is more exposed to scam than any other industry. The health care fraud comes into existence because of the increasing health care cost. Health care deception is seen as an abuse on health care resources. Due to health care fraud, U.S is facing a huge amount of loss every year. Because health care fraud has played such a very important role in raising the cost of health care it has gained a lot of consideration from the government and the United States people. As discussed above, the health care fraud is on the rise because of the increasing medical cost or health care cost. The U.S government has spent the last decade, focusing on investigating health care frauds with the aim of decreasing its occurrence. There are numerous numbers of medical frauds committed by the medical representative or physicians in order to gain financial benefits from their industry. The most commonly practiced frauds are as follows. Upcoding This is the widely practiced mean of medical fraud. Coding a service at a higher level than what was rendered is known as upcoding. The medical representative or the physicians charge higher from the patient then the actual medication. According to the research, majority of individuals have health insurance from government or any other private institutions. This means that the patient expense is being paid by the third party. The physicians and doctors take advantage from this act. Due to the lack of customer knowledge in medical diagnosis and medicines, the doctors diagnose a relatively expensive treatment for a very nominal kind of treatment. Unnecessary services This is the second most commonly practiced fraud in different hospitals and medical care units. Blood tests, urinanalysis, radiographs and x rays are included in the unnecessary services provided by the doctors. The doctors claim that they are performing these tests to be on a safe side. Some claims that these tests are usually done to have a complete history and medical data of the patient, which will help in diagnosing the problem of the patient. Phantom billing Phantom billing is another serious kind of fraud in medical institutions. Over here the doctors or the medical representatives takes undue advantage of limited medical knowledge of the patient. In phantom billing, the patients are charged for services which have not been rendered by the doctors. There are two different ways of performing phantom billing. The first way happens when the physician charges for the service which he has not provided to the patient. Phantom billing is easy, because the customer does not have knowledge of the entire medical test going there …show more content…
The money lost due to transferring a patient includes a possible hospital stay, diagnostic testing, possible surgery charges, etc. If this money outweighs what it would cost to somehow secure specialty coverage, management should look further into the issue.
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