Healthcare fraud and abuse are more prevalent than most people believe. Fraud is the deliberate misleading of a victim to obtain an unlawful or unfair advantage or to deny a victim in a case their legal rights. In an enforcement law, abuse is the actions that are not in line with established sound business, fiscal, medical procedures, or business that results in unnecessary expenses or payments for services or products that are medically inessential or do not follow professionally acknowledged healthcare standards. Health care abuse and fraud are predicted to cost over 60 billion dollars per year (“Johns Hopkins HealthCare LLC,” 2021).
Enacted Specific Fraud
Helen Storey, the owner of a counseling clinic, and Stephanie Fleming, the North Florida Mental Health (NFMH) provider, were found guilty of Medicaid fraud, conspiracy, false claims, and identity theft. Storey and Fleming defrauded the Medicaid program despite being barred from all federal healthcare programs and committing identity theft to increase their profits. Both had taken money from a taxpayer-funded safety net program that provided health care to the neediest people (“United States Department of Justice,” 2021).
The Regulating Body and the Broken Laws
The legislation that was broken in this case was the False Claims Act. Whoever intentionally submits or induces fraudulent claims for payment or filing false claims for approval is subject to this law/act. The Fraudulent Claims Act stipulates that for each false lawsuit filed, a person who breaches the legislation faces civil fines of $5,000 to $10,000, plus potential treble damages (“UCLA Health,” 2021). The False Claims Act is used in many fraud lawsuits. The Department of Justice recovered approximately $2.3 billion in judgment and settlement in civil actions involving false claims and fraud.
The Healthcare Fraud and Abuse Control Program, according to its website, collaborates with state local law enforcement organizations and the bigger picture of the federal to combat healthcare fraud and abuse. When an inquiry is undertaken, state local law enforcement organizations and the bigger picture of the federal are tasked with conducting investigations, audits, and inspections and employing the resources available to them (“The United States Department of Justice Archives” 2020). The United States Attorney’s Office prosecuted the case after being investigated by the Office of Inspector General of the Department of Health and Human Services and the Medicaid Fraud Control Unit of the Florida Attorney General’s Office.
Communication and Information Exchanged Description
Taking crucial precautions to preserve any physical or electronic copies of evidence that may exist during an investigation is critical. This includes network data, hard disk documents, email archives, email messages, text messages, and any other communication gadgets on any company assets, such as tablets or cellphones (Bryan, 2019). During the investigation, information was gathered that proved Storey and Fleming improperly obtained or attempted to gain more than $250,000 from Florida Medicaid by filing false claims with NFMH. According to the evidence, Fleming had also agreed to a five-year ban from participating in any state Medicaid program as a result of a felony conviction for Medicaid fraud in New Jersey. Fleming lied on her application to become a Florida Medicaid provider, claiming that she had never been convicted of a felony or pled guilty or no contest to one.
Explanation of the Case’s Result
Fleming was sentenced to three years and one day in jail, followed by three years of supervised release due to the case. The Storey received two years and one day in prison, and three years of supervised release. The Florida Agency for Healthcare Administration (AHCA) was ordered to pay $219,000 in restitution to both defendants (“United States Department of Justice,” 2021). Fleming and Storey were convicted of healthcare fraud conspiracy, fraud, and aggravated identity theft. Fleming was also found guilty of making misleading representations about healthcare issues.
Conclusion
Healthcare fraud is a severe problem that must be addressed. Steps are taken to ensure that laws and regulations in the healthcare industry are followed. People can fall between the cracks and believe they have gotten away with their misdeeds, but they are detected eventually. Healthcare fraud schemes cost the country billions of dollars every year, resulting in higher out-of-pocket costs and health insurance premiums for consumers. Not only does law enforcement assist with healthcare fraud, but there are also recommendations available online to assist people in recognizing indicators of healthcare fraud and reporting them.
References
Bryan, Tim L (2019). 7 Steps for Conducting a Fraud Investigation. https://www.crowe.com/insights/healthcare-connection/7-stepsfor-conducting-a-fraud-investigation
Johns Hopkins HealthCare LLC. (2021). https://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/h ealth_care_fraud_and_abuse/
The United States Department of Justice Archives. (2020). https://www.justice.gov/archives/jm/criminal-resource-manual-978- health-care-fraud-and-abuse-control-program-and-guidelines
UCLA Health. (2021). http://legal.uclahealth.org/fraud-and-abuse-laws
United States Department of Justice. (2021). https://www.justice.gov/usao-ndfl/pr/floridacounseling-center-owner-and-provider-sentenced-federal-prison-medicaid-fraud
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