As a Chief Nursing Officer, I’m responsible for one of the state’s largest Obstetric Health Care Centers. I just received word of some fraudulent behaviors in the center. To mitigate this type of behaviors I must evaluate how the healthcare Qui Tam affects health care organizations, provide four examples of Qui Tam cases that exist in a variety of health care organizations, Devise a procedure for admission into a health care facility that upholds the law about the required number of Medicare and Medicaid referrals, Recommend a corporate integrity program that will mitigate incidents of fraud and assess how the recommendation will impact issues of reproduction and birth, and Devise a plan to protect patient information that complies with all necessary laws. After completing my evaluation on Qui Tam I will be able to provide a proper protocol to handle or prevent future issue and grow awareness on how fraudulent behavior affects the health care center. Qui Tam is Latin for “he who brings a case on behalf of our lord King, as well as for himself”. Qui Tam allows a private citizen (relator, whistleblower) to bring a lawsuit on behalf of the government, as well as himself, against a defendant who may has knowingly committed fraud or criminal act in which the government was victimized (Showalter, 2012). The private citizen need not have been personally harmed by the defendant’s conduct (Department of the Interior Office of Inspector General, 2010). The government can choose to take over the prosecution, but if the government declines the private citizen can proceed alone. How Healthcare Qui Tam affects health care organizations.
Healthcare is a multi-billion dollar industry and has attracted those who want to defraud health insurance companies and the government (Showalter, 2012). Based on the healthcare industry monetary value it has become the fertile soil for white –collar crimes that end in criminal convictions and financial penalties (Showalter, 2012). The punishment for payment fraud and abuse is shared with the abuser and the organization. When an employee is involved in act of fraud and abuse management, officers as well as the organization is held accountable. They share in the punishment even if management, officers or the organization is aware of the abusers actions. . One way to minimize exposure to fraud and abuse is to have a strong corporate compliance program in place. Developing a strong compliance programs will ensure an organization’s adherence to federal and state regulations such as false claim act, anti-kickback statues, the Starks self-referral laws and HIPAA. Using government regulation as the bases of an organizations compliance program will help significantly in the effort to prevent fraud, abuse and waste within the organization (Showalter, 2012). Healthcare Qui Tam along with state and government regulations has pushed organizations to develop new or stronger compliance programs in the hopes to prevent fraud, promote integrity and improve billing accuracy. Not only has it push health care organization to create compliance program to protect the company these policy also include process for an employee to anonymously report and undesirable conduct they may see. Companies have also created their own fraud and abuse compliance departments that are responsible for educating the staff of any federal and state regulations and created requirement for and standards each depart must to abide by. This department will also be responsible for the investigation of any reported behavior. These measures are put in place to prevent any possible fraud and abuse acts with in the organization. Examples of Qui Tam cases that exist in a variety of health care organizations. To remedy abuse associated with ghost billing, up coding, unbundling, and billing for inadequate or unnecessary care the government put in place the false claims act. During January 2009 through 2012 the justice department used the...
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