Health Care

[Cleo's Mom 257]

F. Healthcare Fraud Criminal Statute.

The Healthcare Reform Law amends the intent

requirement contained in the healthcare fraud criminal statute, 18 U.S.C. § 1347. That statute now

provides that proof of actual knowledge of the healthcare fraud statute or specific intent to violate the

statute is not required. The definition of healthcare offense, 18 U.S.C. § 24(a), is also amended to

include violations of the AKS, the food Drug and Cosmetic Act, and certain ERISA provisions.

The U.S. Sentencing Guidelines are also amended with respect to individuals convicted of healthcare

offenses related to any federal healthcare program. The offense level for such individuals is increased

anywhere from 20 to 50 percent where the loss involves more than a million. In a highly regulated

industry, with a myriad of complex regulations, these provisions effectively increase exposure for a

broad array of business and regulatory activities where there is no specific intent to violate the

provisions of the statute.

II. P

PROGRAM INTEGRITY PROVISIONS

The Healthcare Reform Law contains a host of program integrity provisions that will impact business

operations and require enhanced procedures and policies in all health industry sectors. Some of these

provisions, if violated, may comprise a basis for overpayment or fraud liability. These provisions

include new employee and vendor screening requirements, new financial disclosure requirements, the

requirement of face-to-face physician and patient encounters for DME and home health services, and

new price reporting requirements in the 340B program. Of special note in the program integrity

provisions is the requirement that Medicare and Medicaid providers and suppliers, effective January 1,

2011, include their national provider identifier on all program applications and claims.

[pattygreen 5]

F. Healthcare Fraud Criminal Statute.

The Healthcare Reform Law amends the intent

requirement contained in the healthcare fraud criminal statute, 18 U.S.C. § 1347. That statute now

provides that proof of actual knowledge of the healthcare fraud statute or specific intent to violate the

statute is not required. The definition of healthcare offense, 18 U.S.C. § 24(a), is also amended to

include violations of the AKS, the food Drug and Cosmetic Act, and certain ERISA provisions.

The U.S. Sentencing Guidelines are also amended with respect to individuals convicted of healthcare

offenses related to any federal healthcare program. The offense level for such individuals is increased

anywhere from 20 to 50 percent where the loss involves more than a million. In a highly regulated

industry, with a myriad of complex regulations, these provisions effectively increase exposure for a

broad array of business and regulatory activities where there is no specific intent to violate the

provisions of the statute.

II. P

PROGRAM INTEGRITY PROVISIONS

The Healthcare Reform Law contains a host of program integrity provisions that will impact business

operations and require enhanced procedures and policies in all health industry sectors. Some of these

provisions, if violated, may comprise a basis for overpayment or fraud liability. These provisions

include new employee and vendor screening requirements, new financial disclosure requirements, the

requirement of face-to-face physician and patient encounters for DME and home health services, and

new price reporting requirements in the 340B program. Of special note in the program integrity

provisions is the requirement that Medicare and Medicaid providers and suppliers, effective January 1,

2011, include their national provider identifier on all program applications and claims.

We already have that provision. No one is allowed to overcharge for a service or to charge more than once for the same service. If they do it is fraudulent. Report them.

[BJean 16]

patty: "Where, in this president's plan, does he change all that from happening? No where! "

Good Lord. I didn't say that it does. What I said was that the president and congress have been trying to fix the nearly hopeless system that we have. You are using that sentence to defend the current system that we have? I dunno about you, girl.

As for the double billing, I may have used that term incorrectly. What they have done (not the hospital, btw) is bill for the same service more than once in the same month. I don't believe that is fraud. Now if they got paid for the goods or services and then pretended they didn't and billed me for it separately, then that is fraud and there are laws that prohibit them doing that.

We have an extremely lousy health care system in this country. I've explained this before. It is a system that has evolved and was fueled by the greed of insurance companies. They figured out that if they insure everyone, they can make money in spite of the people who get sick. Then they got even greedier and figured out that they could get away with denying claims for legitimate health issues of the people they insure.

Another issue that caused them grief was that they were getting hit hard for malpractice suits that they were losing and they also figured out a way to make money in spite of malpractice suits. And of course they figured out how to employ hot shot attorneys who are experts at winning malpractice lawsuits for their defendants.

The answer is not in doing away with malpractice lawsuits. Although capping the awards might be worthy of discussion. But we the people have little recourse for a situation where a doctor is grossly negligent and cuts off the wrong foot or takes out a healthy organ or prescribes contraindicated medicine that causes our demise. We need to be able to #1) shut down negiligent doctors and 2) be compensated for having to sustain injuries at those doctor's hands.

And as for the rising cost of insurance premiums with less and less coverage, it is breaking the backs of hard working Americans and small businesses. This is why the president and congress has worked hard and long to make some changes and the Republicans are doing their best to misinform the public about it.