Fraud
Scientific Misconduct
Physician Self-Referral
Democracy
Moscow
Insurance, Accident
Retraction of Publication as Topic
Health care programs: fraud and abuse; revised OIG civil money penalties resulting from public law 104-191. Office of Inspector General (OIG), HHS. Final rule. (1/124)
This final rule revises the OIG's civil money penalty (CMP) authorities, in conjunction with new and revised provisions set forth in the Health Insurance Portability and Accountability Act of 1996. Among other provisions, this final rulemaking codifies new CMPs for excluded individuals retaining ownership or control interest in an entity; upcoding and claims for medically unnecessary services; offering inducements to beneficiaries; and false certification of eligibility for home health services. This rule also codifies a number of technical corrections to the regulations governing OIG's sanction authorities. (+info)Privacy Act; implementation. Office of Inspector General (OIG), HHS. Final rule. (2/124)
This final rule exempts the new system of records, the Healthcare Integrity and Protection Data Bank (HIPDB), from certain provisions of the Privacy Act (5 U.S.C. 552a). The establishment of the HIPDB is required by section 1128E of the Social Security Act (the Act), as added by section 221(a) of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Section 1128E of the Act directed the Secretary to establish a national health care fraud and abuse data collection program for the reporting and disclosing of certain final adverse actions taken against health care providers, suppliers or practitioners, and to maintain a data base of final adverse actions taken against health care providers, suppliers and practitioners. Regulations implementing the new HIPDB were published in the Federal Register on October 26, 1999 (64 FR 57740). The exemption being set forth in this rule applies to investigative materials compiled for law enforcement purposes. (+info)Unconventional dentistry: Part III. Legal and regulatory issues. (3/124)
This is the third in a series of 5 articles providing a contemporary overview and introduction to unconventional dentistry (UD) and its correlation to unconventional medicine (UM). UD presents issues of dental quackery, fraud and malpractice, and it also engenders professional concerns about public protection and professional risks. Case reports illustrate numerous issues. The reader is encouraged to evaluate the cases for problems related to malpractice, fraud, ethics, behaviours and professionalism. A discussion of ethical issues is beyond the scope of this paper. (+info)An on-site audit of the South African trial of high-dose chemotherapy for metastatic breast cancer and associated publications. (4/124)
PURPOSE: The randomized study reported by Bezwoda et al of high-dose chemotherapy (HDC) for treatment of metastatic breast cancer was audited on site to verify the study results. Additional published studies were reviewed to determine whether they had been subject to the required institutional oversight. PATIENTS AND METHODS: Ninety patients were reported to have been randomized and treated on this trial. A log of the names, hospital numbers, entry dates, and regimen received had been provided by the principal investigator. A search of more than 15,000 sets of medical records available from two Johannesburg hospitals was performed to locate records for as many of these 90 patients as possible. Standard auditing techniques were used. Additional clinical trials published by Bezwoda were compared against the minutes of the University of the Witwatersrand Committee for Research on Human Subjects to verify review and approval. RESULTS: Records for only 61 of the 90 patients could be found. Of these 61, only 27 had sufficient records to verify eligibility for the trial by the published criteria. Of these 27, 18 did not meet one or more eligibility criteria. Only 25 patients appeared to have received their assigned therapy temporally associated with their enrollment date, and all but three of these 25 received HDC. The treatment details of individual patients were at great variance from the published data. Nine other trials reported by Bezwoda were not reviewed or approved by the appropriate institutional committee despite statements to the contrary in the publications. CONCLUSION: The multiple publications of this study do not report verifiable data, and nine other publications coauthored by the principal investigator contain at least one major untrue statement. (+info)Fraud-and-abuse enforcement in Medicare: finding middle ground. (5/124)
Medicare fraud and abuse cost billions of dollars each year. Yet Congress is considering legislation to hamper enforcement. Providers' anger over enforcement led to a congressional compromise several years ago to limit excesses. If providers and their advocates were to hobble enforcement, this could provoke a backlash. Instead, the existing compromise should be strengthened to accommodate legitimate provider concerns while allowing enforcement against major fraud and abuse. Government should further confine, structure, and check its discretion in applying the False Claims Act. Enhancing the Health Care Financing Administration's capacity to ensure that contractors pay claims properly would remove additional points of friction. (+info)Consumers versus managed care: the new class actions. (6/124)
The plaintiffs in pending consumer class-action lawsuits against health maintenance organizations (HMOs) should fail in their claims for damages for fraud under federal anti-racketeering legislation. Although HMOs have regularly failed to disclose their business methods and have not strictly honored their contractual coverage promises, the circumstances in which they introduced cost controls into a market sadly lacking them suggest motives not deserving punitive sanctions. Courts could easily find that HMOs violated the Employee Retirement Income Security Act (ERISA), however. Injunctive relief compelling more extensive disclosures and clearer contracts might well legitimize HMOs' methods and generally improve the performance of the health care marketplace. (+info)Medicare program; civil money penalties, assessments, and revised sanction authorities. Final rule with comment period. (7/124)
This final rule with comment period is a technical rule that updates our civil money penalty (CMP) regulations to add CMP authorities already enacted as part of the Balanced Budget Act of 1997 (BBA) and delegated to us. The rule delineates our authority to assess penalties for: failure to bill outpatient therapy services or comprehensive outpatient rehabilitation services (CORS) on an assignment-related basis, failure to bill ambulance services on an assignment-related basis, failure to provide an itemized statement for Medicare items and services to a Medicare beneficiary upon his/her request, and failure of physicians or nonphysician practitioners to provide diagnostic codes for items or services they furnish or failure to provide this information to the entity furnishing the item or service ordered by the practitioner. The rule also contains technical changes to further conform our current CMP rules to changes in the statute enacted by the BBA. (+info)Providing long-term care benefits in cash: moving to a disability model. (8/124)
This paper examines the role of a disability approach to the allocation of long-term care benefits. It first highlights the important elements of long-term care that support a disability model. It then reviews the advantages and disadvantages of this approach relative to the traditional indemnity model and summarizes key features of selected domestic and international programs that offer a disability-type benefit. The paper identifies and elaborates on the major implementation challenges and concludes with a recommendation for further examination of the costs and benefits of this approach to the public coffers, the private market, and long-term care consumers. (+info)In the context of medical law and ethics, fraud refers to a deliberate and intentional deception or misrepresentation of facts, motivated by personal gain, which is made by a person or entity in a position of trust, such as a healthcare professional or organization. This deception can occur through various means, including the provision of false information, the concealment of important facts, or the manipulation of data.
Medical fraud can take many forms, including:
1. Billing fraud: This occurs when healthcare providers submit false claims to insurance companies or government programs like Medicare and Medicaid for services that were not provided, were unnecessary, or were more expensive than the services actually rendered.
2. Prescription fraud: Healthcare professionals may engage in prescription fraud by writing unnecessary prescriptions for controlled substances, such as opioids, for their own use or to sell on the black market. They may also alter prescriptions or use stolen identities to obtain these drugs.
3. Research fraud: Scientists and researchers can commit fraud by manipulating or falsifying data in clinical trials, experiments, or studies to support predetermined outcomes or to secure funding and recognition.
4. Credentialing fraud: Healthcare professionals may misrepresent their qualifications, licenses, or certifications to gain employment or admitting privileges at healthcare facilities.
5. Identity theft: Stealing someone's personal information to obtain medical services, prescription medications, or insurance benefits is another form of medical fraud.
Medical fraud not only has severe legal consequences for those found guilty but also undermines the trust between patients and healthcare providers, jeopardizes patient safety, and contributes to rising healthcare costs.
Scientific misconduct is defined by the US Department of Health and Human Services as "fabrication, falsification, or plagiarism in proposing, performing, or reviewing research, or in reporting research results." Fabrication means making up data or results that never occurred. Falsification means manipulating research materials, equipment, or processes, or changing or omitting data or results such that the research is not accurately represented in the research record. Plagiarism is the appropriation of another person's ideas, processes, results, or words without giving appropriate credit.
Scientific misconduct also includes other practices that seriously deviate from those that are commonly accepted within the scientific community for proposing, conducting, or reporting research. It does not include honest error or differences of opinion.
It is important to note that scientific misconduct can have serious consequences for the individuals involved and for the integrity of the scientific enterprise as a whole. It is essential that researchers adhere to the highest standards of integrity in order to maintain public trust in science and to ensure that research results are reliable and reproducible.
Physician Self-Referral, also known as the Stark Law, is a federal regulation that prohibits physicians from referring their patients to certain healthcare services or providers with whom they have a financial relationship, unless an exception applies. The law is designed to prevent conflicts of interest and ensure that physician referrals are based on the patient's medical needs rather than financial considerations.
The Stark Law covers designated health services (DHS) such as clinical laboratory services, physical therapy, radiology, radiation therapy, durable medical equipment, home health services, outpatient prescription drugs, and inpatient and outpatient hospital services. It applies to referrals made by physicians who have a financial relationship with the DHS entity, such as ownership, investment, or compensation arrangements.
Violations of the Stark Law can result in significant civil penalties, including fines and exclusion from federal healthcare programs. However, there are several exceptions to the law, such as in-office ancillary services, rural provider exceptions, and academic medical center exceptions, among others. It is essential for physicians and healthcare providers to understand and comply with the Stark Law and its exceptions to avoid legal and financial consequences.
Quackery is defined in the medical context as the promotion of fraudulent or unproven medical practices and treatments. Quacks, or individuals who practice quackery, often claim to have expertise in areas of medicine that they do not actually possess. They may use manipulative marketing techniques to exploit individuals' fears and vulnerabilities, promising quick cures or miracle treatments for various ailments.
Quackery can be harmful because it can lead people to choose ineffective or even dangerous treatments instead of evidence-based medical care. It is important for healthcare providers and consumers alike to be aware of quackery and to promote scientific literacy and critical thinking when evaluating medical claims.
I am not aware of a specific medical definition for "democracy" as it is a political science term. However, democracy generally refers to a system of government in which power is vested in the people, who rule either directly or through freely elected representatives. It is based on the principles of equality, freedom, and the rule of law.
In the context of healthcare, the concept of democracy may refer to the idea of patient-centered care, where patients are actively involved in decision-making about their own health and healthcare. This approach recognizes the importance of individual autonomy, informed consent, and shared decision-making between patients and healthcare providers. It also emphasizes the need for transparency, accountability, and responsiveness in healthcare systems and organizations.
Therefore, while "democracy" may not have a specific medical definition, its principles are relevant to the provision of high-quality, ethical, and compassionate healthcare.
I'm sorry for any confusion, but "Moscow" is not a medical term. It is the capital city of Russia. If you have any medical questions or terms you would like defined, I'd be happy to help!
Accident insurance is a type of coverage that provides benefits in the event of an unexpected injury or accident. This type of insurance is designed to help protect individuals from financial losses due to medical expenses, lost wages, and other costs associated with an accidental injury. Accident insurance policies typically cover events such as falls, motor vehicle accidents, sports injuries, and other unforeseen accidents. Benefits may include reimbursement for medical bills, disability payments, or even death benefits in the event of a fatal accident. It's important to note that accident insurance is not a substitute for comprehensive health insurance coverage, but rather a supplement to help cover out-of-pocket costs associated with accidents.
Plagiarism is not a term that has a specific medical definition. It is a more general term that refers to the practice of using someone else's ideas, words, or creative expressions without giving credit to the original author. This can include copying and pasting text from another source without providing proper citation, failing to put quotation marks around borrowed language, or presenting another person's work as one's own.
Plagiarism is considered unethical in academic, professional, and creative settings because it involves stealing someone else's intellectual property and passing it off as one's own. It can have serious consequences, including damage to one's reputation, loss of credibility, and even legal action in some cases.
In the context of medical research and writing, plagiarism is taken very seriously and can result in sanctions such as retraction of published articles, loss of funding, or damage to professional standing. It is important for medical professionals and researchers to always give credit where credit is due and to properly cite any sources they use in their work.
"Retraction of publication" is the process by which a published article or paper is withdrawn from the scientific literature due to significant errors, misconduct, or unethical behavior found in the study. The retraction may be initiated by the authors themselves, the journal editorial board, or the publisher. A retraction notice is typically issued, explaining the reasons for the retraction and providing details about the original publication. This ensures that the scientific record remains accurate and reliable, while also alerting readers to any concerns with the validity of the research findings.
Insurance claim reporting is the process of informing an insurance company about a potential claim that an insured individual or business intends to make under their insurance policy. This report typically includes details about the incident or loss, such as the date, time, location, and type of damage or injury, as well as any relevant documentation, such as police reports or medical records.
The purpose of insurance claim reporting is to initiate the claims process and provide the insurance company with the necessary information to evaluate the claim and determine coverage. The insured individual or business may be required to submit additional information or evidence to support their claim, and the insurance company will conduct an investigation to assess the validity and value of the claim.
Prompt and accurate reporting of insurance claims is important to ensure that the claim is processed in a timely manner and to avoid any potential delays or denials of coverage based on late reporting. It is also important to provide complete and truthful information during the claims process, as misrepresentations or false statements can lead to claim denials or even fraud investigations.
Professional ethics in the medical field are a set of principles that guide physicians and other healthcare professionals in their interactions with patients, colleagues, and society. These ethical standards are based on values such as respect for autonomy, non-maleficence, beneficence, and justice. They help to ensure that medical professionals provide high-quality care that is safe, effective, and respectful of patients' rights and dignity.
Some key principles of professional ethics in medicine include:
1. Respect for autonomy: Healthcare professionals should respect patients' right to make their own decisions about their healthcare, including the right to refuse treatment.
2. Non-maleficence: Medical professionals have a duty to avoid causing harm to their patients. This includes avoiding unnecessary tests or treatments that may cause harm or waste resources.
3. Beneficence: Healthcare professionals have a duty to act in the best interests of their patients and to promote their well-being.
4. Justice: Medical professionals should treat all patients fairly and without discrimination, and should work to ensure that healthcare resources are distributed equitably.
5. Confidentiality: Medical professionals have a duty to keep patient information confidential, unless the patient gives permission to share it or there is a legal or ethical obligation to disclose it.
6. Professional competence: Medical professionals have a duty to maintain their knowledge and skills, and to provide care that meets accepted standards of practice.
7. Honesty and integrity: Medical professionals should be honest and truthful in their interactions with patients, colleagues, and other stakeholders. They should avoid conflicts of interest and should disclose any potential conflicts to patients and others.
8. Responsibility to society: Medical professionals have a responsibility to contribute to the health and well-being of society as a whole, including advocating for policies that promote public health and addressing health disparities.