5530: Chapter 4


Published on

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

5530: Chapter 4

  1. 1. Chapter 4Criminal Aspects of Health Care 2
  2. 2. Baltimore County woman who bilked friends for fakecancer treatments to be sentenced. After seekingmoney from friends, Leone pleaded guilty to felonytheft The message sounded desperate. "I need to raise $1,900 before the end of the night," it said. "My medical bills and everything has totally put us in the poor house. … I want to live and I want to stop losing stuff just because of this cancer.‖ The Facebook plea was from Dina Perouty Leone, who at the time, in June 2009, "was asking everyone and their brother for money," according to the messages recipient, Maurica Marcum, a former classmate of Leones at Sparrows Point High School. 3
  3. 3. Continued"I never would ask anyone or want others to know our business, so please dont tell anyone," Leone continued in her message. "I am just lost.― In fact, Leone had been seeking money from friends and acquaintances for months, prosecutors said, ostensibly to help her pay for treatment of terminal stomach cancer. As far back as October 2004, she wrote an Internet posting saying she had been fighting the disease for "over a year and a half" — only that time it was breast cancer. Later, she said shed had cervical cancer for a decade. None of it was true. October 27, 2010, By Nick Madigan, The Baltimore Sun
  4. 4. Between a Rock and A Hard PlaceBaltimore Woman Accused of Raising Money forCancer Victim and Then Keeping It . . . Rock isaccused of one of the lowest possible crimes: raisingmoney for a 5-year-old girl with cancer and thenkeeping the money for herself. February 1, 2010 5
  5. 5. Lawyers see St. Josephs stent claims growing. . . Frank Ward . . . went to St. Joseph MedicalCenter for a heart procedure, Dr. Mark Midei put astent in his artery after finding a blockage, and nowanother doctor says the blockage was insignificantand the stent wasnt necessary. A total of 585 patientshave received letters from St. Joseph describingsimilar scenarios, after the Towson hospital reviewedthe last two years of Mideis cases. Robert Little, The Baltimore Sun | May 22, 2010 6
  6. 6. Criminal lawCriminal law (also known as penal law) is the body of statutory and common law that deals with crime and the legal punishment of criminal offenses. What is the purpose of criminal law? 7
  7. 7. Purpose of Criminal Law• Maintain Public Order & Safety• Protect Individuals• Punishment as a Deterrent• Rehabilitation What are the definitions of a crime, misdemeanor & felony? 8
  8. 8. Definitions• Crime – social harm defined & made punishable by law.• Misdemeanor – offense punishable by less than 1 yr in jail and/or a fine.• Felony – imprisonment in a state or federal prison for more than a year. What is an arraignment? 9
  9. 9. Arrest & Arraignment• Formal reading of the accusatory instrument – a generic term that describes a variety of documents, each of which accuses a defendant of an offense • includes the setting of bail What is the purpose of a conference with the defendant and prosecutor? 10
  10. 10. Conference• Meeting for purposes of deliberation• Plea bargaining time• Commences with the goal of an agreed-upon disposition – If no disposition can be reached, a case may be assigned to a trial court. Describe the process of conducting a criminal trial? 11
  11. 11. Criminal Trial – I• Jury selection• Opening statements• Presentation of witnesses & evidence – Standard of proof must be beyond a reasonable doubt.• Summations 12
  12. 12. Criminal Trial – II• Instructions to the jury by the judge• Jury deliberations• Verdict – must be unanimous decision• Opportunity for appeal What does the false claims Act of 1986 prohibit? 13
  13. 13. False Claims• False Claims Act of 1986 – Knowingly presenting a false claim for payment. – making a false record to get a false claim paid. – conspiring to defraud the government. – making a false record to avoid an obligation to pay or transmit property to the government. 14
  14. 14. Kickbacks• Laboratory• Architectural Contract• Ambulance Service 15
  15. 15. Health Care Fraud HIPAA• Congress passed HIPAA in 1996.• Provides criminal & civil enforcement tools & funding to fight health care fraud.• HIPAA requires U.S. AG & Sectry of DHHS acting through OIG to establish coordinated national Health Care Fraud & Abuse Control Program.• Program provides coordinated national framework for federal, state, & local law enforcement agencies; the private sector; & public to fight health care fraud. 16
  16. 16. Schemes to Defraud• Need to establish: • Defendant engaged in a scheme constituting a systemic course of conduct • Defendant did so with the intent to defraud more than one person • Defendant obtained property from one or more persons, at least one of whom has been identified 17
  17. 17. Prevention of Fraud - I1. Develop policies & procedures2. Set-up a corporate compliance program3. Communicate organization’scompliance program to employees 18
  18. 18. Prevention of Fraud - II4. Establish monitoring & auditing systems fordetecting fraud5. Publicize a reporting system for reportingcriminal conduct6. Respond to criminal conduct 19
  19. 19. Prevention of Fraud - III7. Periodically review & update thecompliance program8. Cooperate with state & federallaw, enforcement, & regulatory agencies &insurance companies to detect, prevent, &prosecute fraud 20
  20. 20. Fraud Cases I• Healthy Dose of Fraud• Home Care Fraud• Medicare & Medicaid Fraud• False Medicaid Claims• Fraudulent Billing for Laboratory Tests• Physician Bills for Services Not Rendered 21
  21. 21. Fraud Cases II• Pharmacist Submits False Drug Claims• Inaccurate Records & Controlled Drugs• Nursing Facility Stockholder Falsifies Records• Inflating Insurance Claims 22
  22. 22. Fraud and Ethics• Behind every Healthcare Fraud is a LACK OF ETHICAL BEHAVIOR• Unethical Pay to Referring Physicians 23
  23. 23. Falsification of Records• Falsification of medical & business records is grounds for criminal prosecution.• Anyone who suffers damage as a result of falsification of records may claim civil liability.• The provider could lose Medicare & Medicaid funding. 24
  24. 24. False Entries in Operative ReportWhen a surgeon omitted a true entry in his operative report by not indicating that a nonphysician assisted in a patient’s surgery, the surgeon was indicted for falsification of records. 25
  25. 25. The Toxic PharmacistTwo months before his arrest . . . the pharmacist who in 1990 listed his gross income as $48,000 had amassed $18.7 million in total assets. During approximately the same time frame, Robert Courtney would, by law enforcement estimates, dilute 98,000 prescriptions for 4,200 patients. 26
  26. 26. Misuse & Theft of Drug Text Cases• The Toxic Pharmacist• Internet Pharmacy• Conspiracy to Distribute Dilaudid• Illegal Use and Sale of Marijuana• Theft of Drugs• Fraudulent Billing• Distribution of Misbranded Drugs• Abuse Prescribing Controlled Substances 27
  27. 27. Internet PharmacyCustomers would obtain prescription and nonprescription drugs from the Internet pharmacy . . . Dr. Nelson, the defendant in this case, agreed to review the prescriptions, approving 90% to 95% of prescription requests without examining his purported patients. 28
  28. 28. Physicians: Victims of Fraud• Familiarize themselves with patient-billing & recordkeeping practices.• Avoid having one individual in charge of billing & collection procedures.• Arrange for an annual audit of office procedures & records by an outside auditor. 29
  29. 29. Patient AbusePatient abuse is the mistreatment or neglect ofindividuals who are under the care of a healthcare organization.Describe the signs of resident abuse the surveyors look for. 30
  30. 30. Granny CamsGale . . . wasn’t prepared for the rough treatmentand cruel taunts she says her ailing mothersuffered at the nursing home. She cried as anurse’s aide upbraided her mother for failing tostraighten her arthritis-stricken legs. And shewatched in disbelief as an assistant jerked hermother off her rubber bed pad and pushed her intothe bed’s metal rails. 31
  31. 31. Signs of Abuse – I• Physicians order for restraints• Time-limited orders• Number of patients restrained• Type of restraints being used• Restraints applied correctly 32
  32. 32. Signs of Abuse – II• Condition of restrained patients• Restraints released as required by law• Exercise is provided for the patient• Staff response to requests for water, assistance to the bathroom, etc.• Signs of mental & physical abuse 33
  33. 33. Signs of Abuse – III• Restrained patients observed by staff• Signs of harassment, humiliation, or threats from staff or patients• Effect of restraints on patients – signs of overmedication – Frequency of overmedication• Whether patients are comfortable with staff 34
  34. 34. Signs of Abuse – IV• Patients with bruises or other injuries• Patient-to-patient interactions – staff response• Evidence of patient neglect – patients left in urine or feces without cleaning Describe forms of abuse 35
  35. 35. Forms of Abuse• Physical• Psychological• Medical• Financial 36
  36. 36. Abuse Cases - I• Neglect of Residents• Abuse & Revocation of License• Abusive Search• Physical Abuse 37
  37. 37. Abuse Cases - II• Forcible Administration of Medications• Abuse of Stroke Patient 38
  38. 38. Criminal Negligence• Reckless disregard for the safety of others.• Willful indifference to an injury that could 39
  39. 39. Manslaughter• Unlawful killing of another person without malice of forethought.• Voluntary or involuntary – Voluntary manslaughter: intentional killing of another person (e.g., in ―the heat of passion‖) – Involuntary: death occurs as the result of a negligent act. 40
  40. 40. Murder• 3 Shot at Georgia Hospital• Nurse Sentenced for Diabolical Acts• Fatal Injection of Pavulon• Fatal Injection of Lidocaine• Lethal Dose of Anesthesia• Lethal Dose of Codeine• Removal of Life Support Equipment 41
  41. 41. Rape• When one person is forced, without giving consent, to have sexual intercourse with another.• Hospital Held Liable in Patient’s Rape• Sexual Assault Was Foreseeable 42
  42. 42. Theft• Cost Millions Annually• Patient Valuables• Staff Valuables• Supplies• Medical Equipment 43
  43. 43. Theft Cases• Theft of Resident’s Money• Nurse Assistant Misappropriates Resident’s Funds• Commingling Resident’s Personal Funds 44
  44. 44. Sexual AssaultAn action was filed against a nursing facility after the plaintiffs mother was sexually assaulted by a dementia patient. There was testimony that the facility was properly staffed. There was testimony that the resident suffered no physical injury & she was not aware of the assault. What was the Court decision? 45
  45. 45. Court DecisionThe court found that the facility had notbreached its duty of care. 46
  46. 46. Questions - I1. What are the objectives of criminal law?2. Describe the difference between a misdemeanor & a felony. Give an example of each.3. List the processes of a criminal trial. 47
  47. 47. Questions - II4. Why was the False Claims Act of 1986 enacted?5. Why has health care fraud been so costly to the nation?6. Discuss why physicians historically have been reluctant to remove a patients life-support systems. 48
  48. 48. Questions - III7. Discuss why you believe patients are sometimes reluctant to complain about their health care 49