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HSA515 Week 3 Scenario Script: Health Care Policy, Law, and Ethics – Criminal Aspects of Health Care and Antitrust
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Professor Charles enters classroom and introduces the topics for today’s lesson and begins the lecture. Prof Charles: Hello everyone….welcome back to class. Today, we are going to discuss criminal law, antitrust, and health care….
In an effort to provide you a review of criminal law as it relates to the healthcare industry, I will begin with the procedural aspects of criminal law as well as a an overview of cases that have occurred in health care facilities.
A crime is any social harm defined and made punishable by law. The objectives of criminal law are to maintain public order and safety. Crimes are generally classified as misdemeanors or felonies. A misdemeanor is an offense punishable by less than one year in jail and/or a fine ( for example, petty larceny). A felony is a much more serious crime (for example, rape and murder) and is generally punishable by imprisonment.
Let’s first discuss criminal procedure which regulates the process for addressing violations of criminal law. Who can describe the process of arrest and arraignment?
Casey: Prosecution usually begins with a police arrest or a warrant for an arrest. The arraignment is a formal reading of the accusatory instrument, a document which accuses the defendant of an offense and includes the setting of bail.
Donald: I would agree, but I would add that after the charges are read the defendant pleads guilty or not guilty. Then the court sets bail, if any, and the judge sets a date for the defendant to return to court.
Prof. Charles: Absolutely. What happens after the arraignment?
Casey: I would say there is a conference and then the criminal trial.
Prof. Charles: Excellent Casey. What occurs in the conference?
Donald: The conference occurs if the defendant does not plead guilty. Plea bargaining commences with the goal of an agreed-upon disposition. If no disposition can be reached, the case is adjourned, motions are made, and further plea bargaining takes place. After several adjournments, a case may be assigned to a trial court.
Prof. Charles: Great job, Donald! Now let’s take a look at the criminal trial.
Check Your Understanding
Which of the following best represents the defense attorney?
A. Defends the rights of the prosecutor.
B. Protects the rights of the defendant.
C. Represents the interests of the law
Correct Feedback:
B. In protecting the rights of the defendant, the defense attorney is often not very popular and usually sits in the proverbial “hot seat.”
Incorrect Feedback:
A. Defends the rights of the prosecutor.
C. Represents the interest of the law.
Scene 2
Discussion between Prof Charles and students. Prof. Charles: Let’s discuss the False Claim Act of 1986 which prohibits knowingly presenting or causing a false claim for payment to be presented to the government. Also, knowingly making, using or causing to be made or used a false record or statement to get a false claim paid or approved by the government is in the act. Conspiring to defraud the government by getting a false claim allowed or paid is also included in the False Claim Act of 1986.
As a means of reducing fraud and abuses in federal health care programs, the Office of Inspector General (OIG) can impose monetary penalties as well as exclude providers from the participation in Medicare and Medicaid.
.
The federal government requires providers to implement an effective corporate integrity agreement (CIA). Let’s explain the seven core elements of an effective compliance program.
Casey: So, Professor Charles…how is this evidence of complying with the Act?
Prof. Charles: Good question, Casey. The Inspector General says that best evidence that a provider is operating effectively occurs when the provider, through its compliance program, identifies problematic conduct, takes appropriate steps to remedy the conduct and prevents it from recurring, and makes a full and timely disclosure of the misconduct to the appropriate authorities.
Donald: Just to be clear, the seven core elements are as follows:
1. leadership by corporate counsel or a chief compliance officer. written standards
2. Education and training
3. Internal lines of communication
4. Responding to potential violations
5. Corrective action procedures.
Prof. Charles: Excellent Donald… There is also the Medicare and Medicaid Patient Protection Act 1987, the “Anti-Kickback Statute.”
The Act provides for criminal penalties for certain acts impacting Medicare and Medicaid. The statute penalizes anyone who induces, solicits, or pays anything of value to influence another person to use these federal programs. The OIG targets four billing practices: claims for services not provided, claims for beneficiaries not homebound, claims for visits not made, and claims for visits not authorized by a physician.
Casey: I am still not quite clear on this idea of a kickback
Prof. Charles: Sure….Imagine a private laboratory who does laboratory work for a private hospital of which it is part owner. The independent Lab company could be convicted of receiving money from the private hospital in exchange for referring Medicare patients to the hospital.
Check Your Understanding
Health care fraud involves an unlawful act, generally _______ for personal gain:
A. Deception
B. Irregularities
Correct Feedback:
A. Deception is correct. It is intentional and healthcare fraud continues to be a major financial drain in the healthcare system.
Incorrect Feedback:
B. Fraud incorporates not only irregularities but also illegal acts characterized by intentional deception.
Check Your Understanding
Behind every act of fraud lies a lapse in ________:
A. Intuition
B. Belief
C. Ethics
D. Memory lapse
Correct Feedback:
C. Ethical lapses often occur when physicians make referrals based on a financial interest the physician has in the provider to which the patient has been referred.
Incorrect Feedback:
A. Incorrect. Financial self interest is the motivating factor in the ethical lapse.
B. Incorrect. Please try again. The illegal act was based on financial factors not a belief system.
D. Incorrect. Please try again. The physician did not forget right from wrong but did remember his/her illegal self-interests
