Case Study: False Claims Act

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Question I:
Healthcare fraud is intentionally deceiving, providing false statements, or misrepresentation in order to obtain an unauthorized benefit through billing Federal/State insured agencies e.g. Medicare or Medicaid. Fraudulent activity involves the act of knowingly, willfully, and intentionally committed or committed the act with reckless disregard.
False Claims Act (“FCA”) prohibits knowingly presenting or causing to be presented a false claim for payment of government funds. Penalties can include criminal, civil and administrative consequences.: 18 U.S.C. § 287 Criminal prosecution/imprisonment, Civil - 31 U.S.C. §§ 3729-3733 suspension of payments, exclusion from participation in federal health care programs for 5 years or more,
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In the case of US cs. MedQuest Associates, the court held that MedQuest violated FCA though 1) use of non-Medicare approved physicians for contrast studies testing and 2) use of the physician’s number without reporting the change in ownership to Medicare. These two acts lead to hefty fines. However, the US Court of appeals found in favor of the defendants when they ruled that claimant 's use of non-approved supervising physicians for contrast procedures, and subsequent submission of claim for Medicare payment, did not constitute adequate basis for FCA claim under implied false certification theory; and claimant 's use of Medicare billing number belonging to physician 's practice that it controlled did not trigger hefty fines and penalties created…show more content…
Physicians in the US are given the autonomy to prescribe to patients without restriction of drug indication as long as the prescribe drug is given to the patient to help with their ailment in good faith. Physicians give the prescription to the patient to get filled in the pharmacy. The retail pharmacist does not have instant access to their medical records to verify the indication. The pharmacist can verify the drug and the intent of the phycisian. Once confirmed, the pharmacist can fill the prescription regardless of efficacy of the drug on the patient. It is a stretch to implicate the physician for false claims in off label prescribing because the physician is writing the prescription, not submitting the claim. The pharmacist is the person submitting the claim, however they are filling the prescription based on the physician’s intent and good

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