CRIJ110 Criminal Law

Question: Evaluate criminal laws related to health care administration. Analyze ways health care administrators could prevent and address criminal acts. Analyze motivations behind criminal acts. Analyze legal and ethical policy issues in health care administration. Answer: Healthcare Fraud Rudman, Eberhardt, Pierce & Hart-Hester (2009) conducted research on medical fraud and abuse. In Texas, the culprit of healthcare fraud was the supplier of medical equipment as he submitted false Medicare claims. The court convicted him for 120 months of imprisonment along with compensation of $1.6 million to the supplier. However, Raritan Bay Medical Centre decided to pay $7.5 million to the government for the settlement of accusations that it deceived the Medicare program (Rudman, Eberhardt, Pierce, & Hart-Hester, 2009). AmeriGroup Illnois distorted registration into the Medicaid HMO program by denying registration to the pregnant ladies. AmeriGroup compensated $144 million in compensations to the government and Illinois along with $190 million in civil penalties under the False Claims Act as well as the Illinois Whistleblower Reward and Protection Act. General types of fraud and exploitation in healthcare are falsification of services with inappropriate CPT codes; fraudulent billing; altering of claim applications for higher costs; misrepresentation in the health records and such others. Centers for Medicare and Medicaid Services (CMS) assessed that fraud and abuse contributed to about $98 billion to Medicare and Medicaid expenditure in the year 2011. The Medicare-Medicaid Anti-Fraud and Abuse Amendments have established Medicaid fraud control units, the utilization of which has become compulsory for the country. These units include auditors, attorneys, and investigators working independently from the state Medicaid agency of every state, for the purpose of investigating and prosecuting the Medicaid fraud. With the collective efforts of CMS, the Department of Justice, Office of Inspector General of HHS has led the possibility of making criminal healthcare fraud charges against thousands of defendants, criminal convictions, investigations of civil healthcare fraud and recovery of huge amount of money (Health Affairs, 2012). Now, with the use of ‘Twin-Pillar Approach’, CMS is planning to catch fraud much before payments, through fraud prevention system and screening program. References Health Affairs. (2012). Eliminating Fraud and Abuse. Retrieved from Healthaffairs.org: https://www.healthaffairs.org/do/10.1377/hpb20120731.55945/full/ Rudman, W. J., Eberhardt, J. S., Pierce, W., & Hart-Hester, S. (2009). Healthcare fraud and abuse. Perspectives in Health Information Management, 6(Fall).

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CRIJ110 Criminal Law

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