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Read the power point slides and SUMMARIZE the content WITH YOUR OWN WORDS
Chapter 5
Criminal Aspects of Health Care
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LEARNING OBJECTIVES
Explain what criminal law is, the classification of
crimes, and its purpose.
Describe the criminal procedure process from arrest
through trial.
Describe several of the more common crimes that occur
in the healthcare setting.
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Criminal law
Criminal 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?
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Purpose of Criminal Law
Maintain Public Order & Safety
Protect Individuals
Use Punishment as a Deterrent
Provide for Criminal Rehabilitation
What are the definitions of a crime, misdemeanor &
felony?
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Definitions
Crime – social harm defined & made punishable by law.
Misdemeanor – offense punishable by less than 1 year in
jail and/or a fine.
Felony – imprisonment in a state or federal prison for
more than a year.
What is an arraignment?
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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?
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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.
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Criminal Trial – I
Jury selection
Opening statements
Presentation of witnesses & evidence
Standard of proof must be
beyond a reasonable doubt.
Summations
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Criminal Trial – II
Instructions to the jury by the judge
Jury deliberations
Verdict
must be unanimous
Opportunity for appeal
What does the False Claims Act of 1986 prohibit?
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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.
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Ethics in Patient Referral
Act
Prohibits physicians who have ownership interest or
compensation arrangements with a clinical laboratory
from referring Medicare patients to that laboratory.
Requires Medicare providers to report the names &
provider numbers of all physicians or their immediate
relatives with ownership interests in a provider entity.
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Health Care Fraud: HIPAA
Provides criminal & civil enforcement tools & funding to
fight health care fraud.
HIPAA requires U.S. AG & Secretary 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;
private sector; & public to fight health care fraud.
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Kickbacks
Laboratory
Architectural Contract
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Health Care Fraud: Text
Cases
Defrauding Medicare and Medicaid
False Medicaid Claims
Pharmacist Submits False Drug Claims
Inflating Insurance Claims
Falsification of Records
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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.
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Misuse and Theft of Drugs
Internet Pharmacy
Failure to review patient
prescriptions prior to
dispensing.
Fraudulent billing.
Transfer of funds to offshore
account.
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Physicians: Victims of Fraud
Prevention
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.
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Patient Abuse
Patient abuse is the mistreatment or neglect of
individuals who are under the care of a health care
organization.
Describe the signs of resident abuse the surveyors look
for.
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Forms of Abuse
Physical
Psychological
Medical
Financial
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Abuse Cases – I
Criminal Negligence
Reckless disregard for the
safety of others.
Willful indifference to an injury
that could follow an act.
Neglect of Residents
Abuse & Revocation of License
Abusive Search
Physical Abuse
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CRIMINAL NEGLIGENCE
Neglect of Residents
Abuse and Revocation of License
Abusive Search
Medication Violations and Resident Abuse
Assisted Living Facilities
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Murder
Unusual Number of Deaths
Nurse Sentenced for Diabolical Acts
Fatal Injection of Pavulon
Fatal Injection of Lidocaine
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Petty Theft
Cost Millions Annually
Patient Valuables
Staff Valuables
Supplies
Medical Equipment
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Case: Sexual Assault
An action was filed against a nursing
facility after the plaintiff’s 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’s decision?
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Court Decision
The court found that the facility had not breached its
duty of care.
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Review Questions – I
1.
2.
3.
4.
5.
6.
What are the objectives of criminal law?
Describe the difference between a
misdemeanor & a felony. Give an example of
each.
List the processes of a criminal trial.
Why has health care fraud been so costly?
Based on cases in the chapter, discuss why
physicians historically have been reluctant
to remove a patient’s life-support systems.
Discuss why you believe patients are
sometimes reluctant to complain about their
health care.
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