1. Hypothesis: If a physician falsifies care, then consequences will arise
2. Law: False Claims Act (FCA), 31 U.S.C. §§ 3729 – 3733
3. Real Life Legal Case: Pharmaceutical company Novartis Pharmaceuticals Corporation (Novartis), based in East Hanover, New Jersey, has agreed to pay over $642 million in separate settlements resolving claims that it violated the False Claims Act (FCA).
4. Violation: Payments of kickbacks to doctors and illegal use of three foundations as conduits to pay the copayments of Medicare patients taking Novartis’s drugs Gilenya and Afinitor. This violation relates to Medicare and Medicaid payment programs.
1. Hypothesis: If a patient gives free home decor services for care, then civil, criminal and or financial penalties will follow
2. Law: The federal Anti-Kickback Statute (AKS) (See 42 U.S.C. § 1320a-7b.)
3. Real Life Legal Case: On January 28, 2021, the DOJ announced a settlement with athenahealth, Inc. Under the settlement, athenahealth agreed to pay $18.25 million “to resolve allegations that it violated the False Claims Act (FCA) by paying illegal kickbacks to generate sales of its EHR [electronic health records] product athenaClinicals [and athenaOne].”
4. Violation: Athenahealth operated three marketing programs that paid kickbacks to customers in exchange for referring new clients to athenahealth. According to the complaint, one of the marketing programs involved invitations to existing and prospective customers for all-expense-paid sporting, entertainment and recreational events including trips to the Masters Golf Tournament, the Indy 500, New York Fashion Week and the Kentucky Derby with complimentary travel, luxury accommodations, meals and alcohol
In order for healthcare organizations to reduce the risk of false claims and kickback penalties, written policies and procedures must be implemented. Policies and procedures will help to guide organizational operations and create a consistency in practices which will establish clinical expectations and decrease offenses. In addition, responding immediately to detected offenses and implementing appropriate and effective disciplinary measures will help to ensure that illegal payments do not occur. Conducting audits is another way to ensure compliance and minimize exposure risks. Audits will flag errors and questionable activity and bring suspicious pursuits to the forefront.
Healthcare vulnerabilities such as safety issues, medical errors, and cybersecurity pose extreme stressors and threats to patients and communities. Vulnerability can arise as a result of a mismatch between the characteristics of patients and physicians, the healthcare system, the treatment, or the communication between physicians and patients. Vulnerability appears as a gap between a patient’s needs and the means intended to meet them. Vulnerability can further be the result of doing too little or too much for patients. This result suggests that structures provided by healthcare systems are not as differentiated as they should be to cover all situations (Sossauer et al., 2019).
Bricker & Eckler. (2021, February 15). Recent kickback cases yield almost $20 million in settlements for the united states. Retrieved from https://www.bricker.com/insights-resources/publications/recent-kickback-cases-yield-almost-20-million-in-settlements-for-the-united-states
Sossauer, L., Schindler, M. & Hurst, S. Vulnerability identified in clinical practice: a qualitative analysis. BMC Med Ethics 20, 87 (2019). https://doi.org/10.1186/s12910-019-0416-4
The United States Department of Justice. (2021, January 14). Justice news. Retrieved from https://www.justice.gov/opa/pr/justice-department-recovers-over-22-billion-false-claims-act-cases-fiscal-year-2020
Vicky discussion respone
As a patient, how do or would you know if your provider is receiving bonus for referrals? What specifically do you look for to determine if a provider is “transparent . . . in their decision making”? Explain.