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Health care fraud is a form of white-collar crime. The 3 major laws that protect against healthcare fraud are the Anti-kickback statute (anyone), Stark Laws (Physicians), and the False Claims Act.

Many health care organizations are nonprofit and many physicians/health providers are salaried workers. Where are the vulnerabilities in the health system? This discussion will help you and your colleagues to gain an understanding of HCO and professional responsibilities.

To structure PART A (False Claims Act) of your post:

1. State a hypothesis (key statement).
2. Identify the specific law and its statute.
3. From the readings and independent research, find one (1) specific CURRENT real-life legal case that can serve as an example of an HCO’s breach of the False Claims Act, a federal statute. (not sure if you want them to find adjudicated cases?)
4. Note the violation. Does this violation relate to all payment programs (Medicare or Medicaid or Military or Railroad Workers or Indian Health Service or Ryan White) or just about specific ones?
5. Discuss what would help health care organizations equip themselves to ensure compliance and minimize exposure risks like the one that you reported.

To structure PART B (Anti-Kickback Statute or Stark Law) of your post:

1. State a hypothesis (key statement).
2. Identify the specific law and its statute.
3. From the readings and independent research, find one (1) specific CURRENT real-life legal case that can serve as an example of an HCO’s or health professional’s breach of the Anti-Kickback Statute or Stark Law, both federal statutes.
4. Note the violation. Does this violation relate to all payment programs and all health providers or just specific ones?
5. Discuss what would help HCO’s equip themselves to ensure compliance and minimize exposure risks like the one you reported.

To complete this post, you must read the background articles below. This discussion requires research beyond the articles. See Discussion Expectations and Grading for rules on discussions.

Assigned reading materials:

• CMS (2019) Medicare Fraud and Abuse: Prevention, Detention and Reporting https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud-Abuse-MLN4649244.pdf
• Mattie, A., & Ben-Chitrit, R. (2009). The Federal False Claims Act and Qui Tam Actions: What every Healthcare Manager Should Know. Journal of Legal, Ethical and Regulatory Issues, 12(2), 49-68. Retrieved from http://ezproxy.umgc.edu/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=edsgbe&AN=edsgcl.209407528&site=eds-live&scope=site
• Frederiksen, M., & Weaver, E. E. (2015). Understanding the federal physician self-referral statute: “Stark Law”. Journal of Health Care Compliance, 17(2), 47-50,65. Retrieved from Retrieved from http://ezproxy.umgc.edu/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=bth&AN=101416131&site=eds-live&scope=site
• Office of Inspector General, HEAT Provider Compliance Training (n.d.). Comparison of the Anti-kickback Statute and the Stark Law. Retrieved from https://oig.hhs.gov/compliance/provider-compliance-training/files/StarkandAKSChartHandout508.pdf