Le mithetho ikukhusela ekukhohliseni, inkunkuma kunye nokusetyenziswa kakubi
Isixa semali esilahlekile kwi-Medicare ubuqhetseba minyaka yonke siyamangalisa. Akunjalo nje oogqirha . Abanikazi beklinikhi, iinkqubo zesibhedlele, iinkampani zomshuwalense, ii-laboratories, abahlengikazi, oomachiza, abantu baseMedare-nabani na onokwenza ubuqhetseba. Ngakumbi ukwenza inkunkuma kunye nokusetyenziswa kakubi. Ukwahlukana kukuba ukukhwabanisa kubandakanya icebo lokuzikhethela, nangona inkunkuma kunye nokusetyenziswa gadalala, nangona kungengenhloso, kubangele iindleko ezingadingekile kwinkqubo yethu yokunakekelwa kwempilo.
Iziganeko zokuThwala zeMedare
Khangela ezi ziko ukususela ngo-2017. Ngelishwa, ezinye ziqinisekile ukuba zilandele.
- NgoFebruwari 2017, umnini-kliniki waseNew York wagwetywa iminyaka emihlanu entolongweni waza wagwetywa i-$ 8 yezigidi kwizigwebo emva kokuhlawula abantu abangenamakhaya ukuba bafumane iimvavanyo ezingekho mfuneko ezihlawulwa kwi- Medicare neMedicaid .
- Ngo-Meyi 2017, abo babanini-bhorensi abane-Medicare Advantage bavuma ukuhlawula i-$ 32 yezigidi emva kokuba umgcawuli wachaza ukuba iirekhodi zezokwelapha zenziwe ukuba izigulane zibukeke zigula kunokuba zikho, zibangele ukuhlawulwa kwemali evela kurhulumente.
- NgoJuni ka-2017, iMpilo yeGenesis yahlawulisa i-$ 54 yezigidi ukulungisa izigwebo malunga nokuhlawula ngokungabalulekanga nokunyamekela ukulungiswa.
- NgoJulayi 2017, iSebe lezoBulungisa lihlawule i-$ 1.3 billion yenkohliso yokujolisa kwi-Medicaid ne-Medicare. Oogqirha abangama-57, abahlengikazi abangama-162, kunye nabasemasimini abangama-36 bavinjelwe kuzo zonke iinkqubo zempilo zonyango ze-opioid diversion and abuse.
- Ngo-Agasti 2017, ugqirha waseTexas wagwetyelwa iminyaka engama-35 entolongweni waza wahlawulisa imali engama-268 yezigidi zeqhinga lokukhwabanisa kunye ne-Medicaid kunye ne-Medicare. Wayekhoxisa iirekhodi zezokwelapha ukuze ahlawule iimvavanyo kunye neenkonzo zonyango ezingadingekile.
- Ngo-Oktobha 2017, oogqirha abathathu baseNew York bagwetywa iminyaka engama-2.5 entolongweni ngenxa yokuthatha izikhawu kwi-Scheme ye-Medicare yezigidi eziyi-100 kunye ne-laboratory inkampani yaseNew Jersey.
Kutheni Ucinga Ukukhwabanisa Ngaba Ingxaki
Kukho iimali ze-Medicare ezingenamkhawulo ezikhoyo. Akusiyo imfihlo ukuba iNgxowa-mali ye - Medicare Trust ilindeleke ukuba iphelelwe ngo-2028. I-United States ayikwazi ukulahlekelwa nayiphi na loo mali ukukhwabanisa, inkunkuma kunye nokusetyenziswa kakubi. Yingakho urhulumente wesigqeba unemithetho ekhoyo ukuze ajezise abo baxhaphaza inkqubo yezempilo kunye nokufumana imali elahlekileyo.
Le yimithetho, indlela esebenza ngayo, kunye nezohlwayo. Nceda uqaphele ukuba izigwebo ziphantsi kokunyuka kwamaxabiso.
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Isitatimende soKhuselo (AKS)Yintoni?
Amanyathelo phantsi koLungiso lwezoKhuseleko loLuntu ka-1972, iSigqibo sokuShitshiswa koKhuselo (42 USC § 1320a-7b (b)) sinqabela ukutshintshiselana (okanye unikele ukutshintshana) nayiphi na into enokubaluleka (umz. zihlawulwa yinkqubo yezempilo yonxweme.
Umzekelo
Inkampani yeenqwelo-ntliziyo inokunika isifo se- cardiologist ukukhawuleza ukwenza utyando oluninzi ngezixhobo zabo.
Ziziphi iiNtlawulo?
Izigwebo zobugebengu zingabandakanya iifihla ukuya kwii-25,000 zamawaka ngokukhawuleza kunye / okanye iminyaka engamahlanu ejele. Izahlwayo zomntu ziba ziphezulu njenge $ 50,000. Abaphangi be-AKS baya kukhutshwa ngaphandle kokuthatha inxaxheba kwiinkqubo zempilo zonyango ubuncinane iminyaka emihlanu.
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Imithetho yoLwabiwo-mali yeMali (CMP)Yintoni?
Umthetho woLwaphulo lwezeMali woLuntu (42 USC § 1320a-7a) ubeka izigwebo zomntu ngenxa yokuphulwa kweSitatimende soKhuselo-Kickback (AKS). Ukongezelela ekujonganeni nokukhawulwa kwamatyala, izilungiso zomthetho nguMthetho woNonophelo ongenakunqweneleka ngokukhethekileyo uhlawulisa abaphulaphuli ngokulungiselela amalungiselelo ngeenkonzo ezingabandakanywa kwiinkqubo zedolophu, ukwenza iingxelo zobuqhetseba kwiinkqubo okanye kwiikontraka kunye neenkqubo zedolophu, ukuvelisa amabango amanga, ukuhluleka ukubika ukuhlawulwa kwemali, kunye nokuhluleka ukunika urhulumente ukufikelela ngexesha elifanelekileyo kwiirekhodi.
Umzekelo
I-Medicare icela utshintsho lwetshathi ngomhla othize, kodwa iofisi yonyango ayenzi iirekhodi zonyango zifumaneke ngexesha.
Ziziphi iiNtlawulo?
Izahlwayo zomntu zivela kwi-$ 10,000 ukuya kwii-50,000 zama-dollar kuxhomekeke kuphulaphulo. Abadlova nabo banokuhlawula umonakalo ngokuphindwe kathathu inani elithathwe ngokungalunganga.
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Umthetho wamabango amanga (FCA)Yintoni?
Umthetho woBango wamanga, njengokuba siyazi namhlanje, kusekelwe kwisilungiso sika-1986 kumthetho wasemthethweni owadlulelwa ngo-1863. Ukwaziwa ngokuba ngumthetho kaLincoln, okokuqala kwenzeka ngexesha leMfazwe yombutho xa kukho inkxalabo malunga namaqhinga okukhwabanisa ukuthengisa izinto iQumrhu leManyano. Umthetho owenqabela nabani na ukuba bathumele amabango amanga okanye amaqhetseba kumarhulumente karhulumente ukuba ahlawule.
Umzekelo
I-dermatologist inika ibhilikhwe ye- biopsy yolusu engazange yenze.
Ziziphi iiNtlawulo?
Izigwebo zomntu (31 USC § § 3729-3733) zivela kwi-$ 10,781 ukuya kwi-21,563 yebango ngalinye, kunye nexesha eliphindwe kathathu umonakalo okarhulumente obumbiselweyo ngenxa yebango lamanga. Izigwebo zobugebengu (18 USC § 287) zibandakanya ukuvalelwa entolongweni kunye nokuhlawulwa kweefayili ukuya kuma-250,000 kwi-$ 500,000 kunye ne-$ 500,000 nganye kwinkampani.
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I-Statute yeNkcazo yeMpilo yeNkohlakalo yokuTyalaYintoni?
Isigqeba se-Criminal Health Care Statute (18 USC § 1347) ngumqathango woMthetho woKhuseleko loLuntu owenza ukuba kube yinto enobungozi ukwenza (okanye uzame ukuphumeza) icebo lokukhwabanisa inkqubo yenkxaso-mali okanye ukusebenzisa izitatimende zobuxoki ukuze ufumane imali evela inkqubo yezempilo yoncedo.
Umzekelo
I-pharmist ayifaki ukuhambisa inani elifanelekileyo leepilisi ze-opioid kwisigulane. Kunoko, uyaphambukisa iipilisi ngokuthengisa ngokuthe ngqo kwabanye abaklayenti.
Ziziphi iiNtlawulo?
Izigwebo zobugebengu zingabandakanya iifihla ukuya kwii-250,000 zamawaka kunye / okanye ukuvalelwa iminyaka engama-20.
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I-Stark Statute (uMgqirha we-Self-Referral Law)Yintoni?
I-Stark Statute (42 USC § 1395nn) inqabela ugqirha ekwenzeni iinkonzo zempilo kwiziko xa ugqirha (okanye ilungu lentsapho yakhe) unomdla / umnini-mali okanye ilungiselelo lembuyekezo.
Umzekelo
Ugqirha ubhekisela izigulane ngeCOPD kwinkampani yonikezelo ye-oksijini enomfazi wayo.
Ziziphi iiNtlawulo?
Zonke iintlawulo ezivela kuloo mvume mazibuyiselwe kumaqela afanelekileyo. Izahlwayo ze-15,000 zamawaka ziyakunikwa nganye inkonzo enikezelweyo. Kukho nokuba kukho imali eyi-100,000 yokungena kwisilungiselelo esingekho mthethweni. Abaphambukisi banokuthi bangabandakanywa kwiprogram ye-Medicare ngokupheleleyo.
ILizwi
Iibhiliyoni zeedola zihlawulwa kwi-Medicare kunye neMedicaid minyaka yonke. Ingaba ukukhwabanisa kwenziwa ngenjongo okanye inkunkuma kunye nokusetyenziswa kakubi kakubi, akukho mithetho ekhuselekileyo ekukhuselaneni nokulahlekelwa kwezimali kunye nokuhlawulisa abo bafumana imali ngokungafanelekileyo kurhulumente.
Oko sifuna ukunyanzeliswa kwaloo mithetho. Ikamva leMali ye-Medicare Trust lixhomekeke kuyo.
> Imithombo:
> Iinkonzo Zobunyango kunye neendawo zokuhlala kwi-2017: Uluhlu lokusebenza. Imali yezeMpilo. http://www.healthcarefinancenews.com/slideshow/biggest-healthcare-rrauds-2017-running-list. Ukuhlaziywa ngoNovemba 10, 2017.
> I-Medicare yoBuqhetseba. Ofisi yoMphathi Jikelele. https://oig.hhs.gov/fraud/strike-force/.
> I- Medicare Inkohliso, iNkunkuma, kunye nokuShatshazwa: Ukuthintela, ukuThola nokuBika. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/fraud_and_abuse.pdf. Epapashwe ngoSeptemba 2017.
> Ugqirha Wokuzimela. Amaziko e-Medicare neeNkonzo zeMedicaid. https://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/index.html. Ukuhlaziywa ngoJanuwari 5, 2015.
> Iiphampha zeNdlela zoNtsholongwane ezintsha: Ubuqhetseba kunye neMithetho yokuShatshazwa. I-Ofisi yoMhloli-Jikelele, kwiSebe lezeMpilo laseMzantsi Afrika kunye neNkonzo zeNtlalo. https://oig.hhs.gov/compliance/physician-education/01laws.asp.