Reverse Referral Fees,Fraud and Abuse

You are outside counsel to the Marcus Welby Healthcare Corporation, which among its other operations owns a durable medical equipment (DME) subsidiary, which sells equipment for home use such as crutches, wheelchairs, and oxygen concentrators. You learn that the subsidiary has had certain business practices about which you have some question under the Medicare and Medicaid Anti-Fraud and Abuse provisions:

  • Salesmen regularly offer home health agency employees a “premium” whenever their clients order DME from the subsidiary.
  • The subsidiary offers “rebates” to patients who use its equipment.
  • The subsidiary pays hospital and home health agency personnel for assisting its patients in learning how to use its products.
  • Some arterial blood gas test results may have been “massaged a bit” by the DME in order to facilitate Medicare payment for oxygen concentrators.

What advice would you give

question 1.2.Complete the Problem at the top of page 599 “Reverse Referral Fees as a two page paper.

You are outside counsel to the Marcus Welby Healthcare Corporation (MWHC), which is concerned that expenses in some of its ancillary departments are causing it to lose money under Medicare and HMO insurance. It would like to start charging its hospital-based physicians for some of the costs of running their departments. Its current relationship with these physicians is one in which they have exclusive contracts to work in these departments, but no money changes hands between them. The hospital handles all billing, staffing, and overhead, but it bills separately for facility charges versus professional fees, and the physicians keep all the professional fees the hospital collects on their behalf. This is the standard practice in the industry. MWHC has the following suggestions for changing this arrangement:

  • • Have the radiology group pay for services, supplies, personnel, utilities, maintenance, and billing services furnished by the hospital. In a non-hospital, office-based setting, this package would normally cost about $100,000 to $150,000 per year. The hospital will charge the radiology group only $25,000 at first, but increase the charges to $100,000 over four years. Payments are due only if the hospital's gross revenue derived from radiology services exceeds $1,000,000 in the previous year.
  • • The hospital's clinical laboratory, under the direction of the pathology group, would pay the hospital a 20 percent fee for “specimen collection and handling services” when a physician on the MWHC medical staff orders a test from the clinical lab.

What advice would you give?

question 1.3Final Research Paper

.write a research paper on health insurance reform. about 5-7 pages. cite resources

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Answer:

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