Special report on reimbursement. Medicare and Medicaid false claims prosecutions: your clerk's mistake can subject you to criminal penalties!

A number of steps are available to individual and institutional providers to minimize exposure under the new wave of enforcement activity. The first is education: learn what rules apply in your setting and share that knowledge with management and line employees. Second, undertake an independent compliance review to identify and resolve any existing exposure, including voluntary disclosure to the authorities, if appropriate. Third, institute an ongoing program to communicate to all employees not only the content of applicable rules, but also the genuine commitment of management to ensure continuing compliance above other concerns.     

Catch Me if You Can: An Analysis of "Measures Taken to Comply" under the WTO Dispute Settlement Understanding

The objective of the compliance procedure is to ensure promptcompliance with the Dispute Settlement Body's (DSB) recommendationsand rulings through an expeditious procedure. In their assignment,the compliance panels are faced with competing considerationsof, on the one hand, ensuring Members the right of a "reasonableperiod of time" for implementing the DSB's recommendations andrulings and, on the other, ensuring prompt compliance. Compliancepanels have to pay due respect to the fact that an Article 21.5proceeding is not a new proceeding, which limits the scope ofwhich claims may be raised in those proceedings and restrictsthe determination of which measures are "measures taken to comply".In order to achieve those overall aims, compliance panels andthe Appellate Body have accepted that claims other than thoseraised in the original proceedings may be presented in complianceproceedings. Due process principles form an integral part ofthe Dispute Settlement Understanding (DSU). The delicate taskof the panels and Appellate Body is to determine which claims,not raised in the original proceedings, are admissible in anArticle 21.5 proceeding. Compliance panels and the AppellateBody have established several limitations in order to limitthe ambit of potential claims and measures that may fall withinan expeditious Article 21.5 proceeding. However, the embracedapproach to determining which new claims, not raised in theoriginal proceedings, are to be considered in Article 21.5 proceedingsand which measures fall within the realm of measures taken tocomply bears the common characteristics of being subject toan extensive interpretation of Article 21.5 of the DSU.     

Mugshot Exposure Effects: Retroactive Interference, Mugshot Commitment, Source Confusion, and Unconscious Transference

More than 25 years of research has accumulated concerning the possible biasing effects of mugshot exposure to eyewitnesses. Two separate metaanalyses were conducted on 32 independent tests of the hypothesis that prior mugshot exposure decreases witness accuracy at a subsequent lineup. Mugshot exposure both significantly decreased proportion correct and increased the false alarm rate, the effect being greater on false alarms. A mugshot commitment effect, arising from the identification of someone in a mugshot, was a substantial moderator of both these effects. Simple retroactive interference, where the target person is not included among mugshots and no one in a mugshot is present in the subsequent lineup, did not significantly impair target identification. A third metaanalysis was conducted on 19 independent tests of the hypothesis that failure of memory for facial source or context results in transference errors. The effect size was more than twice as large for "transference" studies involving mugshot exposure in proximate temporal context with the target than for "bystander" studies with no subsequent mugshot exposure.     

Corporate compliance and voluntary disclosure

In any event, the decision to institute a corporate compliance program is a relatively simple one. In view of the ambiguity surrounding certain fraud and abuse provisions, and the corporate "death sentence" that may result from program exclusion, a compliance program is always sound corporate policy. To be sure, if the compliance program is administered improperly, it can actually increase the likelihood of whistleblower actions and create a body of potentially hurtful documentation. But these dangers can be minimized by structuring the program to protect the self-evaluative process through relevant privileges. The risks also pale in comparison to the exposure to criminal or exclusionary sanctions when improper conduct goes undetected by an organization.     

In Search of Legitimacy: Toward An Empirical Analysis

Legitimacy is a much used concept in the social sciences. However, the absence of precise operational meaning has prompted questions about its utility as an explanation of compliance with social norms. Most recently, Alan Hyde has argued that legitimacy cannot be disentangled from other explanations of compliance such as coercion and self-interest and should, therefore, be abandoned. However, institutional, attitudinal, and behavioral dimensions of legitimacy can be operationalized. As part of our research on small claims courts we examined variations in institutional processes and legitimacy, gathered data on levels of voluntary compliance, and questioned defendants about their reasons for paying claims against them. We conclude that institutional legitimacy is related to voluntary compliance, and that the "language of obligation" is an important part of normal discourse. Operational meanings for legitimacy are available and empirical research about legitimacy should be a prominent part of the social science research agenda.     

Tension, compression, and shear: directions, stresses, and outcomes of health care cost control

"Control" of health care costs is often portrayed as a struggle between external, "natural" forces pushing costs up and individuals, groups, and societies trying to resist the inevitable. This picture is false. Control includes strenuous efforts by some to raise costs, and by others to resist those increases, and/or to transfer costs to someone else. But all such forces originate in the purposes and interests of individuals and groups. Health care cost control is a struggle among conflicting interests over the priorities of a society, and claims of "inevitability" are simply part of the political rhetoric of that struggle. International experience supports certain conclusions. First, there is no basis for the claim that limits on expenditure growth must threaten the health of (some members of) a society. Second, there is a substantial variety of experience with cost control. Failure in the United States is often presented as evidence of the impossibility of control, but most other countries have succeeded. Finally, control requires the direct confrontation of interests, with substantial build-up of stress. Advocates of expansion are more successful if they can transform compressive forces into efforts to shift the burden onto someone else. Pressures from providers in every country for "privatization" and/or payment by users reflect this recognition of economic interest.     

Valuations – or How to Say the Unsayable

In this paper, the author revisits "the emotive theory of value" and argues that values are not entities but nothing other than "linguistic fictions". Accordingly, valuations—i.e., valuing actions—can be defined as approving or disapproving attitudes of a subject to some object. In this perspective, values cannot be true or false: What we can do is just compare them with regard to strength. As a consequence, value judgments are to be understood as sentences which are used either to say that a subject s values an object o positively or negatively, or to express (evince) a valuation. The author then shows some relations between normative and evaluative discourses. First, he claims that norms as well as valuations are not true or false. Second, he argues that both may be explained or justified, even if the former are usually justified teleologically whereas the latter are explained referring back to the subject's background and life-style. Third, he notes that a legal order originates from the fact that valuations "crystallize" into norms. Finally, the author examines some further questions related to his analysis. In particular, he argues that the different realms of values, e.g., morals, aesthetics, politics, etc., do not correspond to different evaluative attitudes, but to different phenomena and diverse spheres of human life.     

Health claims and other health-related statements in the labeling and advertising of alcohol beverages (99R-199P). Final rule,Treasury decision

TTB is amending the regulations to prohibit the appearance on labels or in advertisements of any health-related statement, including a specific health claim, that is untrue in any particular or tends to create a misleading impression. A specific health claim on a label or in an advertisement is considered misleading unless the claim is truthful and adequately substantiated by scientific evidence; properly detailed and qualified with respect to the categories of individuals to whom the claim applies; adequately discloses the health risks associated with both moderate and heavier levels of alcohol consumption; and outlines the categories of individuals for whom any levels of alcohol consumption may cause health risks. In addition, TTB will consult with the Food and Drug Administration (FDA), as needed, on the use of specific health claims on labels. If FDA determines that a specific health claim is a drug claim that is not in compliance with the requirements of the Federal Food, Drug, and Cosmetic Act, TTB will not approve the use of such statement on a label. Health-related statements that are not specific health claims or health-related directional statements will be evaluated on a case-by-case basis to determine if they tend to mislead consumers. The final rule provides that health-related directional statements (statements that direct or refer consumers to a third party or other source for information regarding the effects on health of alcohol consumption) will be presumed misleading unless those statements include a brief disclaimer advising consumers that the statement should not encourage consumption of alcohol for health reasons, or some other appropriate disclaimer to avoid misleading consumers. TTB believes that the final regulations will ensure that labels and advertisements do not contain statements or claims that would tend to mislead the consumer about the significant health consequences of alcohol consumption.     

Wrongful death claims. Harriton v Stephens. [2002] NSWSC 461. Edwards v Blomeley. [2002] NSWSC 460. Waller v James [2002] NSWSC 462

Studdert J in all three cases went to great length to summarise the global judicial position of "wrongful life" claims. He did not, however, examine in great length how or whether "wrongful life" claims or "wrongful birth" claims are reconcilable with tort and common law principles. Although the cases identify the difficulty in assessing and quantifying damages, they do not directly address the strict legal principles which apply in the assessment of damages. The main conclusion of the three judgments was that no duty of care is owed to the plaintiff in these circumstances and, even if a duty could be established, the impossibility of quantifying damages and public policy considerations warrant the rejection of such a claim: "thus conscience does make cowards of us all." The significance of the decisions cannot be understand. The decisions deny recognition of "wrongful life" claims in circumstances where a disabled person has incurred injuries en ventre sa mere (in the mother's womb) as a result of infections contracted by a plaintiff's mother or genetic material passed on by a plaintiff's parents. Some countries have now legislated for the abolition of "wrongful life and birth" suits. In January 2002 the French legislature passed a Bill overturning the "wrongful life" decision of the Cour de Cassation in Perruche (17 November 2000). As the issue now falls for ultimate determination by the French Senate, the French pro-life movement continues to lobby for the prohibition of "wrongful birth" suits as well. Furthermore, eight States in the United States have prohibited either one or both actions and the State of Michigan prohibited both actions in 2001. It is likely that all three cases will be appealed. The appeal in Harriton will re-examine the viability of a "wrongful life" claim in Australia whereas the cases of Edwards and Waller still need to determine the "wrongful birth" claims brought by the plaintiffs' parents. It is likely that the latter two cases will not be determined until the High Court has considered the Queensland "wrongful birth" case of Melchior v Cattanach, expected to be late in 2002.     

Technological, economic, and political feasibility in OSHA's Air Contaminants Standard

In 1989, after almost two decades of substance-by-substance standard setting, the Occupational Safety and Health Administration (OSHA) promulgated its Air Contaminants Standard, imposing new exposure limits for 376 toxic substances encountered in U.S. industry. In marked contrast to earlier regulations, the Air Contaminants Standard has generated relatively little industry opposition. This paper analyzes the standard in the context of the twenty-year debate over the appropriate role for technological feasibility and economic compliance costs in occupational health policy. The political feasibility of the new standard is traced to OSHA's abandonment of "technology forcing" in favor of reliance on "off-the-shelf" technologies already in use in major firms. While important as an embodiment of OSHA's new "generic" approach to regulation, the Air Contaminants Standard cannot serve as a model for future occupational health policy, due to its reliance on informal, closed-door mechanisms for establishing regulatory priorities and permissible exposure limits.     

Issues raised by respiratory therapy arrangements

In large part due to the foregoing issues, Medicare program officials have focused on respiratory therapy as an area with great potential for abuse, and may well introduce significant reforms in the near future. Accordingly, any contractual arrangements for respiratory therapy programs of the type discussed above should be carefully reviewed for compliance with Medicare requirements and for a realistic assessment of the parties' potential exposure to liability under the anti-kickback statute. At a minimum, these agreements should provide for short "without cause" termination provisions, or include a so-called "jeopardy" provision that permits the parties to renegotiate or terminate their contract if significant changes occur in, or if the current arrangement is found or threatened to be found to violate, applicable law.     

Evaluation of methyl tert-butyl ether (MTBE) as an interference on commercial breath-alcohol analyzers.

Anecdotal reports suggest that high environmental or occupational exposures to the fuel oxygenate methyl tert-butyl ether (MTBE) may result in breath concentrations that are sufficiently elevated to cause a false positive on commercial breath-alcohol analyzers. We evaluated this possibility in vitro by establishing a response curve for simulated breath containing MTBE in ethanol. Two types of breath-alcohol analyzers were evaluated. One analyzer's principle of operation involves in situ wet chemistry (oxidation of ethanol in a potassium dichromate solution) and absorption of visible light. The second instrument uses a combination of infrared absorption and an electrochemical sensor. Both types of instruments are currently used, although the former method represents older technology while the latter method represents newer technology.The percent blood alcohol response curve was evaluated over a breath concentration range thought to be relevant to high-level environmental or occupational exposure (0-361 microg/l). Results indicate that MTBE positively biases the response of the older technology Breathalyzer when evaluated as a single constituent or in combination with ethanol. We conclude that a false positive is possible on this instrument if the MTBE exposure is very high, recent with respect to testing, and occurs in combination with ethanol consumption. The interference can be identified on the older technology instrument by a time dependent post-reading increase in the instrument response that does not occur for ethanol alone. In contrast, the newer technology instrument using infrared and electrochemical detectors did not respond to MTBE at lower levels (0-36 microg/l), and at higher levels (>72 microg/l) the instrument indicated an "interference" or "error". For this instrument, a false positive does not occur even at high MTBE levels in the presence of ethanol.     

An introduction to the law and economics of class action litigation

The consolidation of similar claims for compensation into a single large class of plaintiffs is referred to as “class action litigation.” This practice can have both social costs and social benefits. For an example of the social benefits of consolidating separate claims, if the facts giving rise to the claims are substantially similar, then there may be significant savings in litigation and court administrative costs from presenting those facts once rather a multitude of times. There may, however, be significant social costs to creating a class of litigants and consolidating their claims. For example, this practice may empower those with frivolous negative expected-value claims to wring an unwarranted settlement from the defendant or defendants. The article surveys other sources of social cost and benefit from class-action litigation, reviews the empirical literature on these actions, and examines recent U.S. policy debates about reforming class-action litigation. The article concludes that class-action litigation can have substantial net social benefits but only if courts assiduously oversee the class certification process so as to identify and forestall the social-cost-generating aspects of class-action litigation.     

Home health agencies: targets of anti-fraud and abuse investigations

Increased health care fraud and abuse investigations could result in home health agencies, and other targets, becoming politically acceptable casualties of war in the battle to balance the federal budget. To protect themselves, home health agencies would be well advised to conduct internal fraud and abuse audits on an annual basis and to develop corporate compliance plans (see Newsletter, Vol. 9, No. 7, July 1994, at 16, and next month's issue, which will discuss corporate compliance programs as well as the OIG's new voluntary disclosure program). In addition, purchasers of home health agencies should be especially vigilant of fraud and abuse problems during the due diligence phase of the acquisition and, if problems are discovered, should consider whether voluntary disclosure to the OIG and settlement of any resulting claims is an appropriate condition of closing.     

Promises,Rights and Claims

The paper argues that promise rights presuppose independently existing (if not pre-existing) claims. The argument relies on the Bifurcation Thesis, according to which all claims, and all rights, can be exhaustively divided into two categories: capacity based and exercise based.     

Promoting a culture of fairness: police training,procedural justice,and compliance

Objectives

Academics and practitioners alike are concerned about the potential “double-edged sword” of procedural justice. In the organizational context, procedural justice is expected to increase compliance with supervisors. However, blind, unthinking, or “hard” compliance with supervisors, may lead to anti-organizational behavior and misconduct. The present study examines the moderating effect of a police recruit cultural training program on the relationship between procedural justice and compliance with police supervisors. We expect that providing cultural training will moderate the relationship between procedural justice and “hard” compliance.

Methods

Participants were police recruits at the Queensland Police Academy who were randomly assigned to an experimental (Voice 4 Values) or control condition (business-as-usual training) upon entry into the academy. Recruits in both groups were surveyed pre- and post- training to capture perceptions of procedural justice and compliance with supervisors.

Results

Results suggest that procedural justice mattered less for predicting “hard” or unthinking compliance among the recruits who received the Voice 4 Values cultural training package, compared to those who did not receive the training.

Conclusions

We conclude that while procedural justice may be of interest to policing organizations, it is important that it is not used as a tool to encourage unthinking compliance. We find cultural training reduces the effect of procedural justice on unthinking or “hard” compliance.

     

Comparing the effects of explicit and implicit false-evidence ploys on Mock Jurors' verdicts,sentencing recommendations,and perceptions of police interrogation

In police interrogation, an explicit false claim to have evidence raises important legal and constitutional questions. Therefore, some interrogation manuals recommend implicit false-evidence ploys (FEP) that ask suspects about potential evidence without making a direct claim to possess the evidence. Similar to the hypotheses in a recent study of implicit FEP and confession rates, we hypothesized that individuals would perceive implicit FEP as less coercive and deceptive when compared to explicit FEP that involve direct claims of false evidence. Although mock jurors rated all FEP as highly deceptive and coercive and as more deceptive than controls, we found that participants did not view implicit and explicit FEP differently and that ploy specificity (implicit or explicit) failed to affect verdicts or recommended sentences. These findings suggest that although interrogation trainers and scholars in law and psychology discriminate between the methods, jurors do not.     

Laws and Universality,Laws and History

The article begins by examining two arguments used by Derrida in work published in 1967. The first claims against Lévi-Strauss that an empirical pattern of events cannot be injected into or superimposed onto an historical pattern claiming universality, for then there can be no disconfirmation of what is said. (This argument is used against Marxian history by some who write in the wake of Existentialism, Paul Roubiczek for instance.) The second claims against Foucault that he does not distinguish between reason as part of thinking and language and reason as an empirical historical structure capable of modification along time. The article then discusses the use of very similar if not identical arguments in Derrida’s much more recent work on laws, Force of law. The intelligibility, the interpretability, of laws and their history comes after the laws, not before, and is thus not fully universalisable.     

Qui tam claims: threat to voluntary compliance programs in health care organizations

The Department of Justice (DOJ) reports that after violent crime, health care fraud is the department's top priority. The number of health care fraud investigations pending at the DOJ increased from 270 cases in 1992 to more than 4,000 in 1997. The DOJ's primary weapon in prosecuting health care fraud is the federal False Claims Act (FCA) of 1863 (31 U.S.C. secs. 3729-3733). Almost unique among federal antifraud provisions, the FCA may also be used by "private prosecutors" to file lawsuits on behalf of the federal government charging organizations with submitting false claims to the government. The FCA rewards such whistle-blowers with a share of any resulting recoveries as a bounty and protects them from discharge for filing false claims lawsuits against their employers. It also requires defendants to pay the costs and attorneys fees of successful claimants. Although the private "bounty hunter" features of the FCA data back to the Civil War, these so-called qui tam claims were nearly dormant until 1986, when Congress amended the FCA to revive their use. Following the 1986 amendments, and paralleling the rapid increase in federal reimbursements for health care costs, private qui tam claims have far expanded beyond their traditional purview of defense contracts into the field of health care. By 1997, health care providers were the targets of 54 percent of the 530 private qui tam lawsuits field that year.