Introduction
For an action to be tried under the false claim act, it must have some form of intents. In most cases, honest billing mistakes are not considered as fraud under the false claim act. For a healthcare provider to receive reimbursement, a physician must authorize all the services provided. It is imperative that the provider administers healthcare to the patient in the presence of an authorized physician. Any action outside the provisions of this can be tried in the court of law for payment under mistake fact, the false claim including fraud (Krause, 2015).
Issue
The eminent issue presented in the case study is whether or not the dentists is entitled to bill Medicare for conducting oral screening of nursing home residents. A pertinent issue and information to this case are the fact that the dentist performed cancer screening without the authority or request of an attending physician. Additionally, it is worth noting that the cancer screening was done as part of the routine exam but without the presence of any medical concern.
Rule
According to the provisions presented in the False Claims Act, all the services performed by a provider must be authorized by a physician for the provider to receive reimbursements (Oparil, 2015). Additionally, the services offered by the provider must be carried out as a result of medical concern or a request by an authorized physician. Any activity that violates these provisions can be charged with a false claim and fraud (Krause, 2015).
Application of Rule to the case
According to the provisions presented in the False Claim Act, the decision made by the dentist to bill Medicare for both the services offered is unlawful and can be charged with fraud in a court of law. The dentist provided two different healthcare services performed under different conditions but billed Medicare as a single healthcare service delivery. The first service offered meets all the requirements in the provision presented in the False Claim Act. The dentist offered routine examination residents of a nursing home in an office specially set up by the agency. This indicates that the physicians at the nursing agency authorized the dentist to perform routine examinations on its residents (Weiner & Wettstein, 2013). However, the provision if the second service; oral cancer screening did not meet the criteria for billing Medicare. First, the dentist screened the nursing home patients for oral cancer without the presence or authority of the nursing home's physician.
Also, there was never a request by any attending physician to the dentist to perform oral screening for the nursing home residents. The nursing home set up an office specifically for the dentist to perform routine examinations on nursing home residents. This indicates that the nursing home physicians only authorized him to perform a routine examination and nothing further than that. His decision to perform oral cancer screening was outside his agreement with the nursing home (Weiner & Wettstein, 2013). As a consequence, the decision to perform oral cancer screening at the nursing home was made without the correct procedure. Furthermore, there is not evident to indicate that there was medical concern that required oral cancer screening of the patients. Consequently, the dentist decision to bundle the bills for both services was unlawful. According to the provisions presented in the False Claim Act, the dentist is liable for fraud.
Conclusion
According to the provisions of the False Claim Act, the dentist is guilty of fraud. He should only be reimbursed for the services provided under the right criteria as presented in the provisions. His action to combine the two bills cannot be described as an honest mistake.
Advices
Senior physician and his wife
According to the federal antikickback statues, a physician is prohibited to take the financial incentive to influence his or her decision-making regarding patient referral. The statues prohibit physicians from receiving anything of value to induce referrals of services or items paid for by a federal program. The physician and wife should be advised to stop attracting patient from the hospital using the help of the physician’s referrals. The medical practitioner's decision making is influenced by pleasing his wife through referring patient of the hospital to his wife's new practice.
The dentist
The dentist should not have billed Medicare for both the services offered since one of the services failed to meet the requirement under which Medicare should be billed. He should have billed Medicare for the first service; routine examination instead of bundling the two services and billing them as one. The dentist should only bill Medicare for services offered that fit the criterion for billing. Otherwise it violates the provisions presented in the false claim act.
The physician
According to the federal antikickback statutes, a physician is prohibited to take the financial incentive to influence his or her decision-making regarding patient referral. As a consequence, the physician’s action of referring the patient to Dick's Home where the patients receive a discount and save thousands of dollars is prohibited by the law and should be stopped. Additionally, the physician is violating the provisions in the antikickback statutes by getting a bonus for each patient he refers to the store. He violates further provisions as indicated under the antikickback law: acts of receiving anything of value to induce referrals of services or items paid for by a federal health program.
References
Beik, J. (2014). Health Insurance Today. London: Elsevier Health Sciences.
Krause, J. H. (2015). Truth, Falsity, and Fraud: Off-Label Drug Settlements and the Future of the Civil False Claims Act. Available at SSRN 2648354.
Oparil, R. J. (2015). The Coming Impact of the Amended False Claims Act.Akron Law Review, 22(4), 3. IM
U.S. v. LORENZO | Leagle.com. (2016). Leagle.com. Retrieved 5 March 2016, from http://www.leagle.com/decision/19911895768FSupp1127_11700/U.S.%20v.%20LORENZO
Weiner, B. A., & Wettstein, R. (2013). Legal issues in mental health care. Springer Science & Business Media.
