¶ … Medicare and Medicaid Services (CMS), previously the Health Care Financing Administration (HCFA), that by the time 2011, health care expenditure will arrive at $2.8 trillion, as well as it will bill for 17% of the Gross Domestic Product. As a result, it is no revelation that white-collar offenders observe health care deception as a rewarding effort. Certainly, the General Accounting Office ("GAO") quotes that such deception accounts for up to 10% of entire health care expense (3).
As health care deception outlays taxpayers almost $100 billion a year, federal, as well as state agencies have given health care fraud tribunal a key center of attention. All through her term, Attorney General Janet Reno made impeaching health care fraud a top precedence at the Department of Justice ("DOJ"), subsequent only to brutal offenses (3).
The government focuses its pains to perceive, as well as take legal action against health care fraud in the federal health care insurance programs, Medicare and Medicaid. Statutes passed to deal with fraud in these precise programs have turned out to be requirements for the reason that the government's second largest community program, Medicare, carries on to be an eye-catching target for fraud, as well as abuse (7).
Individuals and organizations licensed by Department of Health and Human Services ("HHS") to accept imbursement under the Social Security Act may focus on Medicare and Medicaid fraud examinations (7). Persons, as well as organizations comprise nursing and rehabilitation centers, hospitals, Health Maintenance Organizations ("HMOs"), intermediate carriers for example private and public clinics, private insurance companies, durable medical equipment ("DME") providers, medical laboratories, physician practice groups, physicians, as well as other certified health care organizations (7).
Quite a few government agencies are in the process of lessening health care fraud. The DOJ, as well as HHS give screening and enforcement of health care fraud regulations. Inside HHS, the Office of the Inspector General ("OIG"), as well as CMS, assisted by the individual states, start and chase investigations of Medicare and Medicaid fraud (3).
Additionally, the OIG utilizes its tolerant prohibition power as an inducement for suppliers to assist in the attempt through a charitable disclosure program. In trials of fraud, DOJ uses the funds of its personal criminal and civil divisions, as well as those of the United States Attorney offices and the Federal Bureau of Investigation ("FBI") (3).
This paper critically evaluates the statutes purposely passed to tackle Medicare and Medicaid insurance fraud, evaluates the fundamentals, penalties, defenses, and safe harbor provisions for each and every statute, as well as concludes with a discussion of accessible legal safe harbor provisions (3).
This paper also discusses the wide-ranging federal statutes employed to impeach health care fraud, together with the False Claims, False Statements, as well as Mail and Wire Fraud Acts, and explains the basics of the offenses, accessible defenses, and penalties valid under each statute. The paper also gives an indication of federal and state government agencies' pains to examine and take legal action against health care fraud (3).
Statutes and provisions specifically enacted to address Medicare and Medicaid fraud
Congress' reply to the mushrooming augmentation in Medicare and Medicaid fraud and mistreatment has been to make stronger existing statutes and to go by new laws that considerably augment the government's aptitude to notice and battle health care fraud and abuse. The effect is a legislative and regulatory scheme that makes civil and criminal restrictions for any person or legal entity that gives health care goods or services in a deceitful or offensive manner. Criminal prosecution might, in addition, be brought under the False Claims Act, as well as other criminal fraud statutes (3).
A. Medicaid False Claims Statute
The Medicaid False Claims Statute criminalizes the constructing of fake statements or representation regarding any requests for claim of benefits or payment, or removal of assets underneath a federal health care program. At the same time as the Medicaid False Claims Statute was passed to aim fake statements or representations specially concerning health care, the preponderance of trials concerning health care fraud and abuse continue to be produced under other statutes (5).
I. Elements of the Offense
The government has got to establish four elements to maintain a conviction under the statute: (i) the defendant made, or caused to be made, a statement of material fact in an application for payment or benefits under a federal health care program; (ii) the statement or representation was false; (iii) the defendant knowingly and willfully made the statement; and (iv) the defendant knew the statement to be false (5).
a. Statement of Material Fact
The...
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