Fraud and Abuse Laws Thirty (30) states and the District of Columbia have enacted false claims statutes so this week you will examine the federal False Claims Act and its application in the practice and business of healthcare. T

Fraud and Abuse Laws Thirty (30) states and the District of Columbia have enacted false claims statutes so this week you will examine the federal False Claims Act and its application in the practice and business of healthcare. The National Health Care Anti-Fraud Association estimates that healthcare fraud costs the United States about $53 billion annually. Some other sources have this amount ranging from $100 to $450 billion. Fraud is a criminal violation and is defined by Title 13 United States Code Section 134?. as ‘knowingly and willfully executing. or attempting to execute. a scheme or artifice to defraud any health care benefit program; or to obtain. by means of false or fraudulent pretenses. representations. or promises. any of the money or property owned by. or under the custody or control of. any health care benefit program.” While important to know. the legal definition of fraud is a mouthful. In plain English, healthcare fraud is an intentional deception or misrepresentation of fact that can result in unauthorized healthcare benefits or payment [someone lies to get money they do not deserve). In contrast to fraud, abuse does not require intent and knowledge of wrongdoing. This being the case: abuse is defined as “healthcare rofessionals’ practices that are inconsistent with sound fiscal: business: or medical practices: and result in an unnecessary cost to the Medicaid program: or in reimbursement for services that are not medically necessary or tflat fail to meet professionally recognized standards for health care." The False Claims Act is a federal fraud and abuse law that imposes punitive [intended as punishment) liability on individuals or business entities that defraud government programs such as Medicare and Medicaid. It is covered along With the Anti-Kickback Statute and the Exclu5ion Statute. Unlike the False Claims Act and the AntieKickback Statute. the Exclusion Statute is not aimed at prohibiting certain behaviors but is strictly aimed at punishing convicted criminal activity. According to Baumann [2013). ‘lt has been stated that exclusion from federal health care programs can be a finanCial death sentence for those in the health care industry who depend on these programs for business." While reading this document is not required, please explore it. It illustrates what legal responSIbilities are required. not optional. in the practice of health care. Fi’aucl giAb-use Laws: False Claims Act (31 United States Cotle (U S C ] Sections 37’29—3733] and 1.3 U.S.C. Section 23.7 fly; the Fraud and Abuse Laws pertinent to healthcare. include each of the (drawing points in your assignment Summarize the purpose of the False Claims Act. the Exclusmn Statute, and the Anti-Kickback Statute Why are each of these needed in healthcare? What are the professional ramifications of being excluded from federal health care programs?

https://www.justice.gov/sites/default/files/civil/legacy/2011/04/22/C-FRAUDS_FCA_Primer.pdf