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Attorneys disagree on how the yet-to-be-published fraud and abuse regulations will be enforced. Some interpret them as "guidelines," others as the "letter of the law." In addition, officials in the Office of the Inspector General say that they are not sure how the regulations will be enforced. Then there's the question of how the Secretary of Health and Human Services will use his official sanction. Is everything perfectly clear?
Deficiencies in the law, and persuasive fraudsters preying on real and imagined health fears, continue to cause great concern to victims, the professions and society as a whole. The Campaign Against Health Fraud has been formed to address this thriving and malignant relic of more desperate times.
Most physicians are aware of the highly publicized aspects of government health care regulation, including attempts at mandatory physician assignment and recoupment of services deemed medically unnecessary. There is less awareness of the potential pitfalls of civil monetary penalties, as many physicians believe they are primarily applicable to false claim allegations. However, the use of civil monetary penalties is increasing as Congress creates new bases of liability. This development leads to the question: Are civil monetary penalties a weapon against fraud or an instrument of federal policy?
Widely reported cases of research fraud have eroded public confidence in scientific research. When funding agencies met last fall they underscored the importance of integrity in the research process and discussed steps that could be taken to promote it.
In a case where a mix up of blood samples was claimed, an identity check was carried out by means of four single-locus-probes. DNA analysis produced identical profiles with two of the probes (MS 31 and MS 43). With the two other probes one matching and one differing fragment could be detected respectively (MS 1 and g3) In addition to the unambiguous statement "no identy", the DNA analysis proved that the tested blood samples must have been those of two closely related people, most probably of brothers and sisters. Attempted fraud can be assumed from these findings. Further investigations and additional DNA analysis which included a blood sample of the brother of the accused, revealed that the sample for the identity check had been taken from the brother and not from the accused himself.
This chapter discusses certain Medicare reimbursement and fraud and abuse considerations for management services organizations (MSOs), medical foundations, and integrated delivery systems. It stresses the necessity of a business plan, the sources of capitalization that might be used in creating an integrated delivery system, and their effect on Medicare reimbursement. It also discusses related party principles and considerations and the Medicare "incident to" regulations. Furthermore, it discusses the application of certain Medicare safe harbor regulations on MSOs' structures and services, and those of medical foundations and integrated delivery systems.
Albert Shu of Willowdale, Ont., is the 1995 winner of the Amy Chouinard Memorial Essay Contest. Named in memory of long time CMAJ and Canadian Journal of Surgery contributor Amy Chouinard, the competition is intended to stimulate interest in medical and health-related writing among journalism students. The winning essay, written prior to Ontario's 1995 provincial election, examined health care fraud in the province and the impact of the photo health card that was introduced by the New Democrats party government.
Physician self-referral, fraud and conflict of interest are causing increasing concern in Ontario, where 100 physicians are now being investigated for such activities. These and related offences recently have been pushed to the top of the agenda of the provincial college, which recently asked physicians to vote on what kind of self-referral regulations they prefer.
President Clinton on August 21 signed into law the Health Insurance Portability and Accountability Act of 1996. Though much of the publicity surrounded passage of the bill centered on the provision of insurance portability, limits on preexisting condition exclusions, and the establishment of a medical savings account pilot project, the bill also includes a major initiative to expand federal efforts to combat fraud and abuse. This overview highlights the most significant elements of that initiative.
Fraud and abuse risks in subacute care concern three major areas: (1) inadequate treatment and quality of care; (2) underutilization of services; and (3) misrepresentation of service capabilities. Strategies on how to manage these risks and guide changes are given.
Since most plans today are based on "cost plus", employers and unions, whose plans were negotiated a long time ago, cannot afford to pay an increase of $13 per amalgam as they were asked to do when new codes for bonded amalgams were added to the provincial fee schedule. Similarly, demanding strains were placed on drug plans when a $16 per tablet medication for migraine headaches was placed on the market. The plan says that if a physician prescribed it, it will be covered. But by whom? And for how long? Dental insurance is not, and has not been for a very long time, a source of profit for the insurance carriers. One large company, for whom I worked for a number of years, just sold all their group dental insurance to a large carrier. Another well-known company has placed their group insurance on the market and is anxiously seeking a purchaser. It is too much to ask of a dental plan (and let's face it, without the plan, the patient may not seek dental treatment) to pay $100 or more for an "examination and one periapical radiograph resulting from the referral of a patient by a general practitioner to a specialist for endodontic treatment." In the case of a difficult diagnosis, this might be entertained, but why charge this fee in every case, even when the patient is holding a radiograph? I am not suggesting that fraud is being committed by a large number of practitioners on a regular basis. At the same time, I think that we must realize that this type of activity may result in the removal of dental "insurance" from the benefits provided by companies to their employees. Most dentists are extremely honest, but the backlash produced by the few who are involved in fraudulent practices is disturbing.
Popular misconceptions view economic crime against workers' compensation systems as victimless and therefore acceptable. This chapter argues that the courts must express strong denunciation of this fraud to engender a climate of deterrence. The law and order approach developed in Alberta, where Workers' Compensation Board investigators are given police powers, is examined.
When a physician by attempting to gain an illegal financial advantage for himself or another person damages the property of somebody in such a way that he produces or maintains an error under false pretense or distortion or suppression of facts, the physician is guilty of fraud. The attempt is a criminal offense. Following terms are discussed in this paper: illegal financial advantage, damage of property, intent, and status proceedings.
Shortly after the death, in 1971, of Cyril Burt, a prominent British psychologist, the authenticity of his accounts of intelligence test results from the largest report sample of MZA's (monozygotic twins reared apart) was challenged. Charges of fraud by Burt's critics and countercharges by his supporters started an acrimonious battle of words in journals, books, and the mass media that seesawed over the decades. It is still not resolved. The problematic ways in which the scientific community and its major organizations and journal editors have dealt or failed to deal with the problem are discussed.
This paper addresses a problem in reporting scientific research. The problem is how to distinguish between justifiable and unjustifiable data selection. Robert Millikan is notorious for an infamous remark that he used all his data when in fact he had used a selection. On this basis he has been accused of fraud. There is a tension here--historians and his defenders see his selection as understandable and legitimate, while current statements about the Responsible Conduct of Research imply his selection was illegitimate. This paper discusses two main issues that arise in assessing his conduct, whether he was intentionally misleading and whether he actually did mislead the scientific community about some facts of nature. It is argued that he was not intentionally misleading, and that it is unlikely that he misled the scientific community.
The research literature on the social determinants of health focuses on socio-economic inequalities and disadvantage. 'Culture' is usually seen as part of this picture of difference--associated with minority status, ethnicity or race; but we also need to address the role of dominant or mainstream cultures in health and well-being. Cultures provide the underlying assumptions of an entire way of life, allowing us to make sense of the world and our lives. This paper argues that aspects of modern western culture are a potent and under-estimated social factor behind drug use and abuse. It draws on a wide range of evidence from different disciplines to suggest that Western culture's emphasis on the material and the individual, in particular, amounts to 'cultural fraud': the promotion of images and ideals of life that do not meet human needs or reflect social realities. This failure is conducive to diminished well-being, including addiction to drug use or other behaviours.
Comparative illustrations of vertebrate embryos by the leading nineteenth-century Darwinist Ernst Haeckel have been both highly contested and canonical. Though the target of repeated fraud charges since 1868, the pictures were widely reproduced in textbooks through the twentieth century. Concentrating on their first ten years, this essay uses the accusations to shed light on the novelty of Haeckel's visual argumentation and to explore how images come to count as proper representations or illegitimate schematics as they cross between the esoteric and exoteric circles of science. It exploits previously unused manuscripts to reconstruct the drawing, printing, and publishing of the illustrations that attracted the first and most influential attack, compares these procedures to standard practice, and highlights their originality. It then explains why, though Haeckel was soon accused, controversy ignited only seven years later, after he aligned a disciplinary struggle over embryology with a major confrontation between liberal nationalism--and Catholicism--and why the contested pictures nevertheless survived.
Assignment of an individual to the population from which it most probably originated based on its multilocus genotype has been widely applied in recent years. In this study, individual assignment based on microsatellite data was used to identify a case of fishing competition fraud. Despite the fact that the true population of origin was most probably not among the reference populations, recent modifications of the assignment tests were used in confidently excluding (p < 0.0001) the possibility of a 5.5 kg salmon (Salmo salar) originating from the fishing competition location, Lake Saimaa (south-east Finland). In fact, the probability of the suspect salmon originating from one of the regions that supply most of Finland's fish markets was found to be over 600 times higher than it originating from Lake Saimaa. When presented with this evidence, the offender confessed to purchasing the salmon at a local fish shop and criminal charges were laid. This study emphasizes the potential practical application of the individual assignment procedure, in particular the usefulness of confidently excluding populations as the origin of an individual. A similar strategy could be also used, for example in suspected cases of illegal poaching, in order to assign or exclude individuals from originating from a claimed population.