Fraud and Abuse

Fraud and Abuse: DME Medicare Compliance Advice Student’s Name Institutional Affiliation Fraud and Abuse: DME Medicare Compliance Advice Legal and Ethical Considerations for Marcus Welby Healthcare As outside counsel for Marcus Welby Healthcare Corporation (MWH), there are a number of concerning business practices occurring within the organization’s Durable Medical Equipment (DME) subsidiary. The subsidiary supplies equipment such as crutches, wheelchairs, and oxygen concentrators for use at home and appears to have adopted business practices that contravene federal laws, particularly those relating to Medicare and Medicaid anti-fraud and abuse. The organization attracts home health agency staff by providing them with a premium. It also gives rebates to its patients, it pays healthcare personnel for assistance with DME products, and it changes arterial blood gas test outcomes in order to get Medicare to pay for it. This essay will investigate these practices, in particular, the Anti-Kickback Statute, False Claims Act, and other laws applicable to healthcare and the functioning of regulation agencies. Finally, the essay will give a complete set of suggestions to resolve these issues. Salesmen Offering “Premiums” One of the first issues is the practice of paying “premiums” to employees of home health agencies when their clients order DME from the subsidiary. The Anti-Kickback statute (AKS) prohibits the offer or receipt of anything of value for referral of items or services reimbursed by federal health care programs such as Medicare and Medicaid. (Banks, 2020) It violates this statute for home health agency employees to receive premiums for referring the agency’s clients to DME supplier. Since there is an inducement offered to refer Medicare/Medicaid patients to the subsidiary, the premium payments are considered kickbacks in violation of federal law. This puts us at risk for hefty fines, both civil and criminal; getting thrown out of the federal healthcare program; and harm to our brand. It is taken seriously by the government, and the healthcare provider is required to follow strict guidelines to prevent this. Accordingly, the subsidiary should immediately stop providing any premiums to employees of home health agencies. The company must assess its commission and bonus structures for salespeople to ensure compliance with the Anti-Kickback Statute (Banks, 2020). To avoid a recurrence of similar breaches, the company must implement a robust compliance program, including training for all relevant staff members. Offering “Rebates” to Patients Another alarming practice is to give “rebates” to patients who use their subsidiary’s DME products. This type of rebate program can lead to violatio...