“Health care fraud”的意思、由来-开放百科全书

The FBI estimates that Health Care Fraud costs American tax payers $80 billion a year.^[2] Of this amount $2.5 billion was recovered through False Claims Act cases in FY 2010. Most of these cases were filed under qui tam provisions.

Over the course of FY 2010, whistleblowers were paid a total of $307,620,401.00 for their part in bringing the cases forward.^[3]

Types

Billing for services not rendered

Often done as a way of billing Medicare for things that never happened. This can involve forging the signature of those enrolled in Medicare, and the use of bribes or "kickbacks" to corrupt medical professionals.^[4]

Upcoding of services

Billing Medicare programs for services that are more costly than the actual procedure that was done.^[4]

Upcoding of items

Similar to upcoding of services, but involving the use of medical equipment. An example is billing Medicare for a power-assisted wheelchair while only giving the patient a manual wheelchair.^[4]

Duplicate claims

In this case a provider does not submit exactly the same bill, but changes some small portion like the date in order to charge Medicare twice for the same service rendered. Rather than a single claim being filed twice, the same service is billed two times in an attempt to be paid twice.^[4]

Unbundling

Bills for a particular service are submitted in piecemeal, that appear to be staggered out over time. These services would normally cost less when bundled together, but by manipulating the claim, a higher charge is billed to Medicare resulting in a higher pay out to the party committing the fraud.^[4]

Excessive services

Occurs when Medicare is billed for something greater than what the level of actual care requires. This can include medical related equipment as well as services.^[4]

Unnecessary services

Unlike excessive services, this fraudulent scheme occurs when claims are filed for care that in no way applies to the condition of a patient, such as an echo cardiogram billed for a patient with a sprained ankle.^[4]

Kickbacks

People engaging in this type of fraud are also subject to the federal Anti-Kickback statute.

Examples

In the case United States ex rel. Donigian v. St. Jude Medical, Inc., No. 06-CA-11166-DPW (D. Mass.) St. Jude Medical, Inc. agreed to pay $16 million to quiet allegations of paying kickbacks to physicians. The whistleblower was able to provide detailed insider information as to the nature of the kickbacks, which ranged from entertainment to sporting event tickets and other gifts. The relator in this case was awarded $2.64 million.{{citation needed|date=December 2011}}

The case United States et al., ex rel. Jim Conrad and Constance Conrad v. Forest Pharmaceuticals, Inc, et al., No. 02-cv-11738-NG (D. Mass.) involved a drug manufacturer selling a drug, Levothroid, that had never been approved by the FDA. These allegations settled for $42.5 million due to multiple whistleblowers stepping forward to provide detailed information on the alleged fraud. The collective reward to the relators in this case was over $14.6 million.{{citation needed|date=December 2011}}^[9]

Copied and pasted entries into the Electronic Medical Record may constitute fraud. A U.S. Department of Veterans Affairs, Veterans Health Administration pulmonologist at the Montgomery, Alabama facility copied and pasted data entered by other physicians into electronic medical records that he signed. The VA Office of the Medical Inspector reported this finding to Congress in 2013.

Reporting fraud

There are many ways to report cases of fraud. If a patient or health care provider believes they have witnessed Health Care Fraud, they are encouraged to contact the FBI via either their local office, telephone, or the online tips form.

If, however, they want to ensure the government actively investigates the alleged fraud, they are encouraged to contact legal counsel from an experienced firm that specializes in qui tam litigation under the False Claims Act. A good legal team can advise potential whistleblowers of their rights, protections, and what evidence is necessary to solidify a case against the group leading the fraud.

See also

References

1. ^{{cite web|url=http://www.justice.gov/usao/tne/health_care.html|title=Department of Justice|publisher=Department of Justice}}
2. ^{{cite web|url=https://www.fbi.gov/about-us/investigate/white_collar/health-care-fraud|title=FBI-Health Care Fraud|publisher=FBI}}
3. ^{{cite web|url=http://oig.hhs.gov/publications/docs/hcfac/hcfacreport2010.pdf|title=The Department of Health and Human Services and The Department of Justice; Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2010|date=January 2011}}
4. ^¹²³⁴⁵⁶⁷⁸{{cite web|url=https://www.fbi.gov/stats-services/publications/fcs_report2006/financial-crimes-report-to-the-public-fiscal-year-2006#Health|publisher=FBI|year=2006|title=Financial Crimes to the Public Report 2006}}
5. ^VA inspector says Alabama doctor's acts may be insurance fraud. USA TODAY NETWORKMary Troyan. Montgomery Advertiser July 29, 2014. http://usat.ly/1mYBGqf
6. ^{{cite web|url=http://www.prweb.com/releases/2011/1/prweb8082432.htm|title=St. Jude Medical, Inc. Settlement|publisher=PRWeb|date=2011-01-21}}
7. ^{{cite web|url=http://www.justice.gov/opa/pr/2011/January/11-civ-078.html|title=Justice News|publisher=Department of Justice|date=2011-01-20}}
8. ^{{cite web|url=http://www.prweb.com/releases/2010/09/prweb4525334.htm|title=Forest Whistleblower Cases Settle for Over $300 million|publisher=PRWeb|date=2010-09-15}}
9. ^{{cite web|url=http://www.justice.gov/opa/pr/2010/September/10-civ-1028.html|title=Drug Maker Forest Pleads Guilty|publisher=Department of Justice|date=2010-09-15}}

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