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Fraud
Published in Julie Dickinson, Anne Meyer, Karen J. Huff, Deborah A. Wipf, Elizabeth K. Zorn, Kathy G. Ferrell, Lisa Mancuso, Marjorie Berg Pugatch, Joanne Walker, Karen Wilkinson, Legal Nurse Consulting Principles and Practices, 2019
The physician self-referral law is commonly known as Stark Laws after the initial passage by Congressman P. Stark (42 USC § 1395nn). Stark I was enacted as part of the Omnibus Budget Reconciliation Act of 1989 (Stark Law, 2010, 2013). The focus of this statute is to prevent inappropriate financial influences over physicians’ decisions about the best care for their patients. However, the prohibitions set forth in this statute have caused uncertainty among providers as they struggle to respond to various market forces on cost constraints. The self-referral law, as enacted in 1989, prohibits a physician from referring a patient to a clinical laboratory in which the physician (or an immediate family member) has a financial relationship.
Medicare and the affordable care act: Fraud control efforts and results
Published in International Journal of Healthcare Management, 2018
Sarah Clemente, Ronald McGrady, Robert Repass, David P. Paul III, Alberto Coustasse
The AKS was enacted in 1972 and has been amended multiple times to address ‘kickbacks’ (any compensation or financial arrangement in which a provider knowingly receives, is offered, or solicits a fiscal benefit of any kind for referrals, purchases, etc.). To physicians and, similarly to the FCA, required the statute to be broken knowingly to be considered fraud [33]. To remain within the guidelines of the AKS providers have operated within ‘safe harbors’ or regulatory exclusions which have been addressed explicitly in the law. However, consistent with the changes to the FCA, the AKS has been recently amended by the ACA to remove the requirement that a violation is performed knowingly [34]. In 1992, the Stark Law was enacted to address physician self-referral but was limited to referrals to clinical laboratories. However, that law has subsequently been amended to include a multitude of diagnostic and treatment self-referrals of Medicare patients by physicians or their family members [35].
Factors affecting hospital services overutilization and reductive strategies in Iran: a qualitative study to explore experts’ views
Published in Hospital Practice, 2022
Leila Doshmangir, Hossein Jabbari, Morteza Arab-Zozani, Mohammad Naghavi-Behzad, Zeinab Abedi, Hakimeh Mostafavi
This paper explored the viewpoints of the main stakeholders of the Iranian health system about the overutilization of hospital services and appropriate strategies to eliminate or reduce this phenomenon in Iran. Overutilization of hospital services in the Iranian health system is a common issue that deserves many studies. Therefore, identifying the factors affecting this issue and presenting preventive strategies can lead Iran’s healthcare system to better productivity. Our findings as the key stakeholder perspectives showed that site of service, quality of services, supplier push, and demand pull are the most categories of factor affecting hospital service overutilization, and to save resources, increase the satisfaction of patients, and get better health results, use of appropriate strategies for managing the utilization of health services is vitally necessary. The findings of this study imply that payment schemes, especially Fee-For-Service (FFS), unregulated patient access to secondary and tertiary care, free provider choice, and lack of a strong supervision and monitoring system are the main reasons for the waste of resources and services overutilization. Similar to our findings, the American Board of Radiology Foundation implies that FFS, defensive medicine, practice behavior of referring physician, self-referral, patient expectations, and lack of enough knowledge of health-care providers of drivers of unnecessary utilization are the factors related to overutilization of radiology services in the United States [40]. Hendee et al. (2010) reported that the significant rate of medical care interventions including prescription medications, tests, and procedures are unnecessary [45]. They mentioned fear of malpractice, difficulty accessing medical records, and patient pressure/request as the most cited reasons for overtreatment. These results are also consistent with the findings of our study in the field of hospital services overutilization.