Dealing with Fraud
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 intentionally fraudulent activities such as billing for services not provided, billing for services or equipment that is not medically appropriate, or violating clearly stated billing rules are unacceptable and should be prosecuted whenever they occur.
Qui tam effect on health care organizations has not been a positive one. Cruise (2003) state that qui tam actions has forced organizations to develop a new cadre of operating guidelines and procedures collectively called “compliance programs” resulting in organizations having to pay $600 – 700 million per year to a consultant industry to advise them on the intricacies of this new era. Health care organizations have adopted Federal Sentencing Guidelines as a part of their compliance programs due to the laws governing Medicare fraud and abuse (Cruise, 2003). Examples of Qui Tam cases that exist in a variety of health care organizations.
Healthcare is on the rise in the United States. Medicare and Medicaid is the largest of the government sponsored healthcare plans and provide health care coverage for as many as 95 million Americans, at an estimated cost in 2012 of more than $900 billion (Raspanti, n.d.). Raspanti (n.d.) state that the primary reason for the rise in healthcare cost has been the large degree of fraud committed against these two major government health care programs. Raspanti (n.d.) state the following are examples of qui tam cases, but not limited to: “Kickbacks: The federal Anti-Kickback Statute prohibits any offer, payment, solicitation or receipt of money, property or remuneration to induce or reward the referral of patients or healthcare services payable by a government health care program, including Medicare or Medicaid. These improper payments can come in many different forms, including, but not limited to: referral fees; finder’s fees; productivity bonuses; discounted leases; discounted equipment rentals; research grants; speaker’s fees; excessive compensation; and free or discounted travel or...
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