Dealing with Fraud

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Dealing with Fraud
Health Care Policy, Law, and Ethics
HSA 515
March 09, 2013

Dealing with Fraud
Obstetric health care centers are a major source for providing care to millions of women around the country and a branch of medicine that involves pregnancy and childbirth. Studies of pathologic and physiologic functions of the female reproductive area are also a part of obstetric care. Physicians in this field commonly referred to as OB/GYNs and care for the mother and fetus during pregnancy. As Chief Nursing Officer of one of the state’s largest Obstetric Health Facilities countless women are treated at this center. The staff is fully aware of the mission, vision, policies, and procedures that make a huge impact in the community. Women rely on the care and attention received from the exceptional physicians on staff. Unfortunately, the type of care delivered and the service the hospital is responsible for providing, word of fraudulent behaviors have been reported and must be addressed.

As United States health care cost continues to rise, people depend upon privately funded health plans and millions are still uninsured due to funding by state and federal government. The major government sponsored health care plans are Medicare and Medicaid programs. Both programs make up a large portion of government spending. One key reason for rising costs has been the enormous degree of fraud committed against government health care programs. Although billions have been exposed due to informants of qui tam, additional monies remain undetected. Ultimately, health care fraud used as a deceptive means to profit from health care agreements through the federal government and the reason the United States Government Accounting Office has categorized Medicare and Medicaid as “high-risk programs.” Various sources evaluate the effect of qui tam in health care organizations and refer to the 1986 False Claim Act the effectiveness. The term “whistleblowing” recognized by provisions in the False Claims Act and authorizes cases be brought to the government on behalf of the United States to share in the recovery efforts. The “Informer’s Act” or better known as “The Qui Tam Statue is from the Latin phrase “qui tam pro domino rege quam pro seipse,” meaning “he who as much for the king as for himself,” established during the civil war and focused on ending dishonest suppliers to the union military. Therefore, fraud investigation, and legal action became easier for the government. The history behind qui tam statue and today’s use provides an understanding to the term “whistleblower” and for an individual with past or present knowledge of fraud on the federal government to recover damages and impose penalties, (Cruise, “n.d.”). Fraudulent behavior or health care fraud affects health care organizations. Several ways businesses and individuals have defrauded, and continue to defraud, federal, and state government health care programs. Examples of fraudulent behavior include: • No Services: Non-submission of claims for diagnostic tests, treatments, devices, or pharmaceuticals services that were never rendered. • Non Existence: Involves submitting a claim for the services previously mentioned and provided to patients that do not exist or never received service. Also an item billed for in the claim. • Anti-Kickback Statute: bans any offer, payment, solicitation or receipt of money, property or remuneration to persuade or reward patient referrals or health care services funded by a government health care program, including Medicare or Medicaid. These are improper payments and come in several different forms, includes but not limited to: referral fees, finder’s fees, productivity bonuses, research grants, excessive compensation, and free or discounted travel or entertainment. The offer, payment, solicitation or receipt of any such monies or remuneration can be a violation of the Federal Anti-Kickback statute, 42 USC §1328-7b(b), the Federal False Claims...
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