Fraud and Abuse Enforcement Essay Assignment
Assignment Directions
Explore the OIG Enforcement Actions page. Review and select one of the articles on a case of health care fraud.
Write a 700- to 1,050-word analysis of the case in which you:
• Summarize the incident and the specific fraud that was enacted.
• Discuss what laws were broken and which regulatory bodies are responsible for oversight of the regulations that were violated.
• Describe the communications and information that would have been exchanged among the regulatory bodies and the offending
organization during the investigation and charge of fraud or abuse in the case.
• Explain the outcome of the case. If a judgment has not yet been passed, what do you think the outcome of the judgment should be?
Justify your response.
Format your citations according to APA guidelines.
Submit your assignment. Fraud and Abuse Enforcement Essay Assignment
Fraud and Abuse are common issues in the current healthcare systems. They entail various deceptive intentions and activities to secure unlawful and unfair gains. According to Villegas-Ortega et al. (2021), fraud and corruption in healthcare systems emanate from abuse of power and dishonesty that can harm health service consumers and result in economic and even human losses. For example, health insurance fraud (HIF) can have adverse consequences, including weakening health systems, widening health gaps, and creating resource deficiencies. The estimated costs of corruption and fraud in global healthcare systems are between 10% and 20% of annual health expenditures. Consequently, law enforcement agencies should implement robust strategies to prevent and address fraudulent activities in healthcare settings. This paper elaborates on an incident of fraud, the broken law, regulatory bodies responsible for oversight of the regulations, communications, and information, and the case’s outcome.
The Incident of Fraud
The fraud case involved Stockton Doctor, Azizulah “Aziz” Kamali, and his medical corporation, Aziz Kamali, M.D. According to US Attorney Phillip A. Talbert, the doctor agreed to submit millions of dollars of false claims to Medicare for surgically implanted neurotransmitters and pay kickbacks to sales marketers (The United States Department of Justice, 2022). Further, the defendants falsely claimed to have conducted expensive and invasive surgical procedures to obtain millions of dollars from Medicare fraudulently. These activities egregiously violated the patients’ trust for illegitimate financial gains.
The Broken Law and Regulatory Bodies Responsible for Oversight
The defendants broke the False Claim Act (FCA) of 1863. According to Adashi & JD (2022), this law primarily focuses on the illegal submission of claims for payment to Medicaid, TRICARE, and Medicare that are false and fraudulent. Therefore, the Act provides legal directions and remedies for civil damages when a person or organization engages in various fraudulent activities, including making false statements or participating in a deceptive course of conduct that causes the government to pay out money or forfeit due payments. Upon establishing that a person or an organization engaged in a false claim, the FCA requires the party to pay three times the amount of reimbursement for each fraudulent claim (Adashi & JD, 2022). Further, violating the False Claim Act attracts a civil penalty of $5,500 to $11000 per violation. However, the government can reduce the penalty if the party who perpetrated the fraud reports or substantively cooperates with the government in the investigation process.
Various regulatory bodies oversee and ensure that healthcare organizations comply with the False Claim Act (FCA). These regulatory agencies are the Department of Justice, the Department of Health and Human Services Office of Inspector General (OIG), and the Centers for Medicaid & Medicaid Services (CMS) (Office of Inspector General, 2021). The agencies play a significant role in ensuring compliance with the False Claim Act and other related laws like Anti-Kickback Statute, Physician Self-Referral Law, and Exclusion Statute. Fraud and Abuse Enforcement Essay Assignment
Communications and Information
The effectiveness of the fraud investigation process relies massively upon the quality of evidence provided and the level of communication between regulatory bodies. Bryan et al. (2019) argue that the initial stage of investigating fraud entails receiving and reacting to allegations. The second stage is establishing an investigative team, while the third phase entails conducting a preliminary assessment. During the fourth stage, investigative agencies should collect evidence by preserving electronic and hard copy evidence sources, including network files, documents stored on hard drives, emails, email archives, and text messages (Bryan et al., 2019). Further, investigative agencies should analyze financial, electronic, and business records alongside conducting interviews to ascertain the basis of fraud allegations and develop a comprehensive report of the findings. In the case, the Department of Health and Human Services Office of Inspector General (HHS-OIG) conducted the investigation, revealing that Dr. Kamali and Kamali Inc. violated Anti-Kickback Statute and the False Claim Act.
The Outcome of the Case
The defendants jointly agreed to pay the US government the sum of $1,963, 953.59 as the settlement amount, which is restitution, by electronic transfer according to the written instructions provided by the Office of the United States Attorney for the Eastern District of California. Further, Kamali and Aziz Kamali, M.D. Inc admitted that they fraudulent submitted claims to Medicare for surgically implanted neurotransmitters even though they did not perform surgery or implant neurostimulators (The United States Department of Justice, 2022). It is essential to note that the defendants cooperated with the investigative agencies and admitted to violating the False Claim Act. This factor fastened the case’s rulings and averted more fines and financial sanctions.
Conclusion
Healthcare fraud and corruption pose serious challenges, causing massive resource deficiencies and widening health inequalities. As noted in the fraud case involving Dr. Kamali and his medical corporation, violating the False Claim Act (FCA) of 1863 is a profound challenge in the US healthcare system. In this sense, making false claims to Medicare, Medicaid, and TRICARE has cost the nation billions of dollars annually and has increased out-of-pocket expenses. As a result, investigative and oversight agencies like the Department of Justice, the Department of Health and Human Services Office of Inspector General (OIG), and the Centers for Medicaid & Medicaid Services (CMS) have a responsibility for ensuring that healthcare organizations comply with anti-fraud statutes like the False Claim Act, Anti-Kickback Law, Physician Self-Referral Law, and Exclusion Statute. Fraud and Abuse Enforcement Essay Assignment
References
Adashi, E. Y., & JD, I. G. C. (2022). Health care fraud: The leading violation of the False Claims Act. The American Journal of Medicine, 558–559. https://doi.org/10.1016/j.amjmed.2021.12.014
Bryan, T. L., Poirier, C. L., & Wiese, C. S. (2019). 7 steps for conducting a fraud investigation. https://www.crowe.com/insights/healthcare-connection/7-steps-for-conducting-a-fraud-investigation
Office of Inspector General. (2021, September 1). Fraud & abuse laws. https://oig.hhs.gov/compliance/physician-education/fraud-abuse-laws/#
The United States Department of Justice. (2022, August 12). Stockton doctor and medical practice agree to pay nearly $2 million to resolve allegations of health care fraud. https://www.justice.gov/usao-edca/pr/stockton-doctor-and-medical-practice-agree-pay-nearly-2-million-resolve-allegations
Villegas-Ortega, J., Bellido-Boza, L., & Mauricio, D. (2021). Fourteen years of manifestations and factors of health insurance fraud, 2006–2020: A scoping review. Health & Justice, 9(1). https://doi.org/10.1186/s40352-021-00149-3 Fraud and Abuse Enforcement Essay Assignment
