HSA 515 Dealing with Fraud

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Dealing with Fraud

Demetrice Armwood

Dr. James Coon, Jr

HSA 515 Health Care Policy, Law, and Ethics

June 16, 2013

As the Chief Nursing Officer of the state’s largest Obstetric Health Care Center, this author is responsible for complaints regarding fraudulent behavior in the center. The purpose of this report is to (1) evaluate how the Healthcare Qui tam affects health care organizations, (2) provide four examples of Qui Tam cases that exist in a variety of health care organizations, (3) devise a procedure for admission into a health care facility that upholds the law about the required number of Medicare and Medicaid referrals, (4) recommend a corporate integrity program that will mitigate incidents of fraud and assess how the recommendation will impact issues of reproduction and birth, and (5) Devise a plan to protect patient information that complies with all necessary laws.

Qui Tam (from the Latin phrase “he who sues on behalf of the king”) is a well-known mechanism used by private individual to assist the government in enforcing specific laws (Ruhnka, Gac, & Boerstler, 2000). The False Claims Act of 1863 is one of the most important examples of the Qui Tam mechanism that was enacted during the Civil War to prosecute war profiteers who were caught overcharging the Union Army (Ruhnka, Gac, & Boerstler, 2000). Showalter (2012) states that the whistle-blower (aka relator) files the suit as a kind of “private attorney general” on behalf of the government in a qui tam case. Evaluate how the Healthcare Qui tam affects health care organizations.

Healthcare qui tam affects health care organizations in many ways. The most popular and inconvenient way is financial losses. If an organization is accused of qui tam, a suit is filed and if the company is found guilty of fraud, they stand to incur a financial loss due to having to repay money to the government. Ruhnka, Gac, & Boerstler (2000) state that...
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