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False Claims Act Reply to each Peer about their post.

False Claims Act Reply to Martina:

For this week’s discussion, we primarily focus on the False Claims Act and coding practices. The False Claims Act is the most effective and powerful way to protect the federal government from fraud and/or abuse. In 1863, this act was created in order to be used during the Civil War, to protect certain suppliers from cheating the army. As time went on, the False Claims Act continues to be used today as a way to fight any false claims through any kind of government contract. Specifically, the False Claims Act prohibits “…false claims for payment, the knowing use of false records or statements to support such claims, the knowing and improper retention of money owed or belonging to the federal government, or conspiring with others to commit any of those acts” (Moseley, 2015, p.4).

One of the most common cases that fall under the False Claims Act is when a provider submits a claim for Medicare/Medicaid reimbursement, showing that the services provided were necessary for the patient and were actually given to the patient. Otherwise, if a provider provides a false claim without any proof of it being true, they are submitting to the False Claims Act. A good example of this kind of case specifically happened back in March of 2020 in Mississippi.

In Mississippi recently, there was a Medicare fraud case that occurred that almost costed about $11 million in damage. This case went through jury trials and found that many were found guilty in submitting false claims to Medicare resulting in $10.85 million. Based on this case, “The case centered on millions in fraudulent Medicare reimbursement for the compensation for individuals who purportedly ran a small critical access hospital in rural Mississippi, when in fact, those individuals did little to no work for the hospital” (Yoder, 2020). This case was discovered by the Department of Justice through a whistleblower, James Aldridge by the qui tam provisions under the False Claims Act. He and the jury discovered that individuals were submitting false claims through corporate entities they owned in order to receive monetary value in return.

References

Moseley, G. B. (2015). Managing legal compliance in the health care industry. Burlington, MA: Jones & Bartlett Learning.

Yoder, T. (2020, March 18). Jury Verdict in Qui Tam False Claims Act Medicare Fraud Case Finds Nearly $11 Million in Damages. Retrieved from https://www.natlawreview.com/article/jury-verdict-qui-tam-false-claims-act-medicare-fraud-case-finds-nearly-11-million

False Claims Act Reply 2 Yanira:

Hello everyone,

For this week’s discussion, we’re discussing the False claims acts, and some cases or examples regarding this act.

According to Moseley, G.B(2015) “The FCA was enacted by Congress in 1863 at the height of the American Civil War. In prosecuting that war, the federal government used a large number of private contractors, some of whom took advantage of the crisis situation to make false claims for payment. The FCA was designed to address those abuses. After the war, the Act was largely unused until significant amendments in 1986 lowered the barriers and raised incentives for enforcement. More recently, the Act has been further expanded in the Fraud Enforcement and Recovery Act (FERA) of 2009 and the Patient Protection and Affordable Care Act (PPACA) that became law in 2010. The PPACA is the broad scope health reform act that Congress passed in that year.” This law helps protects companies, but also the patient’s health insurance coverage. There have been cases where physicians bill and rebill for certain dates of services or add to patient’s visits for services that were not provided to the patient. Personally, think this happens to people that are from low income because they use Medical insurance which is the government insurance, and most of the times, these patient’s doctor’s visits are covered without any issues, and gives more of an opportunity to the physician to be able to bill for more services, even for services that were not performed on the patient. Before I started working in the medical field, I was offered a job as a receptionist in an internist’s office, I was really excited to start working my first “real” job ever. The day I walked into the office, there was a doctor getting arrested for “insurance fraud”. I didn’t know at the time exactly what was happening until they told me that they couldn’t hire me because the doctor got arrested and the office was going to be forced to shut down. The doctor was billing for services that weren’t performed, and billing and creating different days of services on certain patients. Although I had no idea what was going on, I was forced to attend court because technically I was an employee. I obviously asked the reason for his arrest and was then disclose the situation of the doctor and the facility.

References:

Moseley, G. B. (2015). Managing legal compliance in the health care industry. Burlington, MA: Jones & Bartlett Learning.