The field of healthcare and medicine can be described as a sensitive field since it involves dealing with the lives of human beings. Medical professionals have to ensure that they do not violate the basic rights of individuals when practicing. However, there can be instances when clients have been treated and then pursue legal actions or physicians can engage in criminal activities. Healthcare-related crimes are generally considered under white collar crimes and could thus be prosecuted by the federal government or the state. The analysis of criminal law in healthcare involves the consideration of healthcare fraud, medical malpractice, falsification of records, and financial or physical abuse cases.
Criminal health care fraud is a criminal offence that involves a wide range of health care crimes. Kyriakakis (2015) describes health care fraud as the knowing misrepresentation or concealment of truth that are generally intended to deceive patients so as to part with their money or property. Fraudulent activities could include several acts such as billing for services that have not been rendered, submitting duplicate claims to third-party payers, billing for unnecessary procedures, and billing for unrelated patient’s conditions. Thornton et al., (2015) analyzed the different types of fraud and established that the most common ones include improper coding, phantom billing, kickback schemes, using wrong diagnosis, and the provision of unnecessary care.
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Medical malpractice in healthcare involves the having various forms of commissions and omissions as a result of the varying degree of negligence by the medical professional. Thiels et al., (2018) observe that surgical trainees that were without supervision were the ones that mostly engaged in medical malpractice. The individuals made decision errors that resulted in harm to the patient and the result was that lawsuits were filed against them. Medical Malpractice claims are common in the United States. Medical professionals thus choose to purchase malpractice insurance that would cater for the costs involved in a malpractice claim (Heller, 2017). For one to successfully file a medical malpractice lawsuit, the injured patient should show that the physician acted with negligence and the result was the injury. The legal requirements that should be proven include a professional duty owed to the patient, the breach of such a duty, the injury as a result of the breach, and the resultant damages. In case of a successful claim, the patient would be awarded money that takes into account both the economic and non-economic loss such as suffering and pain.
Another common fraud in the United States is through Medicare and Medicaid fraud. Clemente et al., (2018) estimates that Medicare and Medicaid fraud can account up to 10% of the entire spending. The fraud involves claim of medical health care reimbursement and the claimant is not entitled to such a claim. The main goal is thus to collect money from the program illegitimately. Legislative reforms have however been made through the Affordable Care Act to fight such types of fraud.
Federal law is used to prosecute people that engage in health care fraud. The law can be divided into to the general applicability and one that is specified to healthcare. General applicability could include general types of fraud such as wire fraud and mail fraud that were not enacted to specifically combat healthcare fraud. The other types of law were created to combat health care fraud such as the federal health care fraud statue and the Medicare and Medicaid fraud statue (Kyriakakis, 2015). For a successful prosecution, proof is required to show that the offender devised a scheme to defraud and enacted with the intention to engage in fraud. The maximum penalties can include fines up to $250,000 and up to 20 years of imprisonment (Kyriakakis, 2015). The penalties vary depending on the amount of damage as a result of the fraud.
References
Clemente, S., McGrady, R., Repass, R., Paul III, D. P., & Coustasse, A. (2018). Medicare and the affordable care act: fraud control efforts and results. International Journal of Healthcare Management, 11 (4), 356-362. http://mds.marshall.edu/cgi/viewcontent.cgi?article=1191&context=mgmt_faculty
Heller, T. A. (2017). An Overview of Medical Malpractice Law in the United States Including Legislative and the Health Care Industry’s Responses to Increased Claims. Medicine, Law & Society, 10 (2), 139-163. Retrieved from https://journals.um.si/index.php/medicine/article/download/2463-7955.10.2.139-163.2017/61
Kyriakakis, A. (2015). The missing victims of health care fraud. Utah L. Rev ., 605. Retrieved from https://dc.law.utah.edu/cgi/viewcontent.cgi?article=1097&context=ulr
Thiels, C. A., Choudhry, A. J., Ray-Zack, M. D., Lindor, R. A., Bergquist, J. R., Habermann, E. B., & Zielinski, M. D. (2018). Medical malpractice lawsuits involving surgical residents. JAMA surgery, 153(1), 8-13. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5833625/
Thornton, D., Brinkhuis, M., Amrit, C., & Aly, R. (2015). Categorizing and describing the types of fraud in healthcare. Procedia Computer Science, 64 , 713-720. Retrieved from https://www.sciencedirect.com/science/article/pii/S1877050915027295
