Le mithetho ikuvikela ekukhwabaneni, ekuthunjweni nasekuhlukunyezweni
Inani lemali elahlekelwa ukukhwabanisa ngemithi njalo ngonyaka liyamangaza. Akuyona nje odokotela noma. Abanikazi bekliniki, izinhlelo zesibhedlela, izinkampani zomshuwalense, laboratories, abahlengikazi, abemithi, abantu baseMedare-noma ubani angenza ubuqili. Ngisho nakakhulu ukuchitha nokuxhashazwa. Umehluko wukuthi ukukhwabanisa kuhilela uhlelo lokuzikhandla, kanti ukungcola nokuhlukunyezwa, nakuba kungenzi ngamabomu, kubangele izindleko ezingadingekile ohlelweni lwethu lokunakekelwa kwezempilo.
Amakhomikhali Eyaziwa Ngama-Fraud Fraud
Bheka lezi zimo kusukela ngo-2017. Ngeshwa, ngaphezulu kukhona okuqinisekile okulandelayo.
- NgoFebruwari 2017, umnikazi waseKliniki waseNew York ugwetshwe iminyaka emihlanu ejele futhi wagwetshwa imali engu-8 million ezigayeni ngemuva kokukhokhela abantu abangenamakhaya ukuthi bahlolwe ngokwemithi ekhokhwa ku- Medicare naseMedicaid .
- Ngo-May 2017, ababhalisi ababili be- Medicare Advantage bavuma ukukhokhela izigidi ezingu-32 zamaRandi ngemuva kokuba ummeli eveze ukuthi amarekhodi ezokwelapha ayenziwa ukuze enze iziguli zibukeke zilukhuni kunalokho, okuholela ekukhokhelweni okuphezulu kukahulumeni.
- Ngo-June 2017, uGenesise Healthcare wakhokhela u-$ 54 million ukuxazulula izinsolo mayelana nokukhokhiswa kokunakekelwa okungenasidingo nokunakekelwa kokuvuselelwa.
- NgoJulayi 2017, uMnyango Wezobulungiswa wehlisa imali eyi-$ 1.3 billion yokukhwabanisa okubhekiswe eMedicaid naseMedareid. Abahlengikazi abangu-57, abahlengikazi abangu-162, kanye nabahlengikazi abangu-36 bavinjelwe kuzo zonke izinhlelo zokunakekelwa kwezempilo eziphethwe yi-opioid diversion and abuse.
- Ngo-Agasti 2017, udokotela waseTexas ugwetshwe iminyaka engu-35 ejele futhi ukhokhe imali engamaRandi ayizigidi eziyizigidi ezingu-268 ngenxa yokwenza ubuqili nokukhwabanisa noMedicaid noMedareid. Wakhohlisa amarekhodi wezokwelapha ukuze athole izivivinyo nezinsiza ezingadingekile zezokwelapha.
- Ngo-Okthoba 2017, odokotela abathathu baseNew York bagwetshwe iminyaka engu-2,5 ejele ngenxa yokuthatha izikhalo emayini ye-Medicare yezigidi eziyizigidi eziyizigidi ezingu-100 neenkampani yezobuchwepheshe eNew Jersey.
Kungani Ukuveza Inkohliso Kuyinkinga
Kunezikhwama zokwelashwa ezilinganiselwe ezitholakalayo. Akuyona imfihlo ukuthi i- Medicare Trust fund kulindeleke ukuba iphelelwe ngo-2028. I-United States ayikwazi ukulahlekelwa yiyiphi yale mali ekukhwabaneni, ekudleni nasekuhlukumezweni. Yingakho uhulumeni wesifundazwe unomthetho endaweni yokujezisa labo abasebenzisa uhlelo lokunakekelwa kwezempilo nokubuyisela imali elahlekile.
Le yimithetho, ukuthi isebenza kanjani, kanye nezijeziso zabo. Sicela uqaphele ukuthi izinhlawulo zitholakala ekukhuleni kwamandla emali.
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Isitatimende se-Anti-Kickback (AKS)Kwenzenjani?
Yenzelwe ngaphansi kwezinguquko zokuphepha kwezenhlalo ka-1972, isitatimende se-Anti-Kickback (42 USC § 1320a-7b (b)) sinqabela ukushintshaniswa (noma unikeze ukushintshanisa) noma yini enenani (isib. Izifumbathiso, izikhalo, izikweletu) zokudluliselwa kwezinsizakalo zikhokhwa wuhlelo lwezempilo lwezempilo.
Isibonelo
Inkampani yensiza yensiza inganikeza isazi se- cardiologist ukukhahlela ukwenza imisebenzi eminingi ngamadivayisi abo.
Yiziphi izigwegwe?
Izijeziso zobugebengu zingabandakanya izinhlawulo ezifika ku-$ 25,000 ngokukhawuleza kanye / noma iminyaka emihlanu ejele. Izijeziso zomphakathi zingaba ngaphezu kwama- $ 50,000. Izidakamizwa ze-AKS nazo zizokhishwa ekuhlanganyeleni ezinhlelweni zokunakekela ezempilo okungenani iminyaka emihlanu.
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Umthetho Wezentengiselwano Zezimali Zomphakathi (CMP)Kwenzenjani?
Umthetho Wezobulungiswa Emali Yomphakathi (42 USC § 1320a-7a) ubeka izigwegwe zomphakathi ngokuphulwa kwesitatimende se-Anti-Kickback (AKS). Ngaphandle kokubhekana nezikhalo, ukuchitshiyelwa komthetho yi-Care Affordable Act kubeka ngokuqondile ukuhlukumeza abahlukumezi ngokuhlela izinsizakalo ngamabhizinisi akhishwe ohlelweni lwezinhlelo zikahulumeni, okwenza izitatimende zokukhwabanisa ngezicelo noma izinkontileka ngezinhlelo zikahulumeni, ukudala izimangalo zamanga, ukwehluleka ukubika ukukhokhelwa ngokwezimali, nokuhluleka ukunikeza uhulumeni ukufinyelela okufika ngesikhathi kumarekhodi.
Isibonelo
I-Medicare icela ukuhlolwa kwamashadi ngosuku oluthile, kodwa ihhovisi likadokotela alenzi amarekhodi wezokwelapha atholakale ngesikhathi.
Yiziphi izigwegwe?
Izijeziso zomphakathi zivela ku-$ 10,000 kuya ku-$ 50,000 kuye ngokuhlukumeza. Abahlukumezi nabo kufanele bakhokhele umonakalo kuze kube kathathu inani elibikiwe ngokungalungile.
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Umthetho wamangalo wamanga (FCA)Kwenzenjani?
Umthetho Wezinkolelo Zamanga, njengoba sazi namuhla, kusekelwe ekuchibiyelweni kuka-1986 komthetho wokuqala owadluliselwa ngo-1863. Futhi owaziwa ngokuthi uMthetho kaLincoln, waqala ukuqala phakathi neMpi Yombango lapho kunokukhathazeka mayelana nezinhlelo zokukhwabanisa ukuthengisa izinto i-Union Army. Umthetho ovimbela noma ubani ngokuhambisa ngokuzenzekelayo izimanga zamanga noma ezikhohlisayo kuhulumeni wesifundazwe ukuze akhokhe.
Isibonelo
I-dermatologist ihambisa umthethosivivinywa we- biopsy yesikhumba engakaze yenze.
Yiziphi izigwegwe?
Izijeziso zomphakathi (31 USC § § 3729-3733) zivela ku-$ 10,781 kuya ku-$ 21,563 ngokumangalelwa, kanye nokulimala kukahulumeni wesifundazwe ngenxa yesimanga samanga izikhathi ezintathu. Izijeziso zobugebengu (18 USC § 287) zifaka ukuboshwa kanye nezinhlawulo zobugebengu kuze kufike kumaRandi ayizigidi ezingama-250 000 umuntu ngamunye kanye ne-$ 500,000 yenhlangano ngayinye.
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Isitatimende Sokukhwabanisa Kwezempilo Lwase-Criminal HealthKwenzenjani?
Isitatimende se-Criminal Health Care Fraud (18 USC § 1347) yisihlinzeko soMthetho wezokuThuthukiswa koMphakathi okwenza kube yisenzo sokuqeda ngenhloso (noma ukuzama ukwenza) uhlelo lokukhwabanisa uhlelo lokunakekelwa kwezempilo noma ukusebenzisa izitatimende zamanga ukuze uthole imali kusuka uhlelo lokunakekelwa kwezempilo olusemthethweni.
Isibonelo
I-pharmist ayifuni isibalo esifanele samaphilisi e-opioid kumguli. Esikhundleni salokho, uhlukanisa amaphilisi ngokuthengiswa ngqo kwamanye amaklayenti.
Yiziphi izigwegwe?
Izinhlawulo zobugebengu zingabandakanya izinhlawulo ezifika ku $ 250,000 kanye / noma ukuboshwa iminyaka engama-20.
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Isitatimende seStark (uMthetho Wokuzimela Ngogqirha)Kwenzenjani?
Isitatimende saseStark (42 USC § 1395nn) sivimbela udokotela ekwenzeni ukuthunyelwa kwezinsizakalo zezempilo enhlanganweni lapho udokotela (noma ilunga lomndeni wakhe) enesithakazelo somnikazi / utshalomali noma ilungiselelo lesinxephezelo.
Isibonelo
Udokotela ubhekisela iziguli ezine- COPD ekhamphani yokuhlinzeka nge- oksijini enomkayo .
Yiziphi izigwegwe?
Zonke izinkokhelo ezivela kulokho okuthunyelwe kumele zibuyiselwe kumaqembu afanele. Isijeziso se $ 15,000 singasungulwa ngenkonzo ngayinye enikeziwe. Kungase kube khona imali eyi-$ 100,000 yokufaka ilungiselelo elingekho emthethweni. Izidakamizwa zingasuswa ohlelweni lwe-Medicare ngokuphelele.
Izwi elivela
Amabhiliyoni amaRandi akhishwa kuM Medicare naseMedicaid njalo ngonyaka. Kungakhathaliseki ukuthi ukukhwabanisa kwenziwa ngamabomu noma ukuchitha nokuhlukunyezwa kwenzeka ngokungenakuqondakala, kunemithetho ekhona yokuvikela kulokho kulahlekelwa ngokwezimali futhi ubenze icala labo abaphutha imali ngohulumeni.
Okudingayo ukuqiniswa kwaleyo mithetho. Ikusasa le-Fundare Trust Fund lixhomeke kulo.
> Imithombo:
> Ukukhwabanisa kwezeMpilo nokuHlaliswa kweMpilo ngo-2017: Uhlu lokugijima. Izimali zezeMpilo. http://www.healthcarefinancenews.com/slideshow/biggest-healthcare-frauds-2017-running-list. Kubuyekezwe ngo-Novemba 10, 2017.
> Medicare Strike Force Force. Ihhovisi le-Inspector General. https://oig.hhs.gov/fraud/strike-force/.
> Medicare Ukukhwabanisa, Inkunkuma, Nokuhlukunyezwa: Ukuvimbela, Ukuthola, Nokubika. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/fraud_and_abuse.pdf. Kushicilelwe ngo-September 2017.
> I-Physician Self Referral. Amasevisi we-Medicare neMediicaid Services. https://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/index.html. Kubuyekezwe i-Januwari 5, 2015.
> Iphepha Lomgwaqo Wezinyanga Ezintsha: Imithetho Yokukhohlisa Nokuhlukunyezwa. Ihhovisi le-Inspector General, uMnyango WezeMpilo waseMelika kanye Nezinsizakalo Zabantu. https://oig.hhs.gov/compliance/physician-education/01laws.asp.