Dealing with Fraud

Institutional affiliation
Dealing with Fraud
In common law, Qui Tam is described as an act by a private person who
has prior or present knowledge of fraud to act legally on behalf of the
federal government (Gumbert, 2003). Such persons are referred to as a
“whistleblower” or “relators” and they usually benefit from filing
Qui Tam in that they are given a part of the benefits obtained from the
defendant. Nearly anybody can initiate a Qui Tam act, encompassing
former or present staff of the body swindling the government and private
individuals. Qui Tam falls under the United State’s False Claims Act.
There must be considerable infringement of federal government rules and
regulations for a legal action to initiate. It is true that health care
organizations carry out certain dealings with the federal government
such as making claims for services provided to Medicaid and Medicare
patients (Gumbert, 2003). With reference to this, this paper focuses on
Qui Tam and its impacts in health care organizations. Besides, the paper
presents an admission procedure plan into a healthcare facility,
corporate integrity program for mitigating fraudulent cases, and a
patient information protection plan.
How the Healthcare Qui Tam Affects Health Care Organizations
Studies show that fraud in healthcare is leading as far as current Qui
Tam cases are concerned (Slade, 2000). This is based on the fact that
about 60 percent of the filed Qui Tam cases entail suspected healthcare
fraud. Some of the main subjects of the legal actions encompass hospital
chains, pharmaceutical companies, nursing home chains, physician groups,
and home health agencies. These entities may engage themselves in
various conducts that results in Qui Tam actions. These conducts
encompass falsification of information by drug manufacturers in order to
obtain approval, infringement of the Medicare anti-kickback statute,
incorrectly certifying medical need, or falsifying diagnosis codes by
physicians, or intentional misrepresentation of information concerning
the calculation of capitated fee rates (Gumbert, 2003).
According to Mundy (2010), private individuals are permitted by Qui Tam
law to take action against fraudulent entities. As a result, they are
able to recover funds and for this reason receive compensation. This is
a major effect of the health care organizations as they are subjected to
loose funds through the recovery. Once an entity is found culpable of
the fraudulent act, it is necessitated to refund fully all the money
given by the government. Besides, such an entity may be necessitated to
pay civil penalties and these differ with regard to the level of
infringement (Mundy, 2010). An example of these penalties encompasses
Civil Money Penalty (CMP) and typically causes adverse effects on the
financial position of an entity. Another effect of the Qui Tam law is
that it results in poor image of health care organizations once the
fraudulent acts have been confirmed. The law has been efficient in
deterring fraud linked with health care organizations.
Examples of Qui Tam Cases that Exist in Health Care Organizations
There exist numerous examples of Qui Tam cases in the health care
setting. Some of such cases encompass Medicare and Medicaid fraud, false
bid claim, false certification, and flawed pricing. To begin with,
Medicare and Medicaid fraud are among the main rampant and common
sources of Qui Tam in healthcare. Government audits show that in so far
as 10 percent of Medicare charges are falsified (The Department of
Health and Human Services, 2011). With an aim of obtaining refund from
Medicaid and Medicare programs, private individuals as well as health
care entities result in making deceitful claims. Through these claims
the federal government has lost huge amount of money. Some of the
conducts that result in healthcare Qui Tam encompass falsifying
diagnosis codes by physicians, intentional misrepresentation of
information concerning the calculation of capitated fee rates, billing
for a similar service for over one time, completion of the Certificate
of Medical Necessity by another person instead of the general
practitioner, waiving of copayments regularly, as well as charging of
healthcare services that have not been provided (The Department of
Health and Human Services, 2011). The law has been efficient in
deterring fraud linked with health care organizations, and through this,
the government has been able to recover some of the funds lost by way of
fraud. For instance, Mundy (2010) puts forth that by 2010, the
government of the United States had been able to recover more than 20
million US dollars from a number of hospitals. This has acted as a
lesson for most organizations, and has resulted in low Medicaid and
Medicare spending.
Flawed pricing is another case of Qui Tam. In this, an organization or
private individual submits to the government inflated prices on
contracts being negotiated upon. Under the False Claims Act, it is
illegal to charge unjust prices for equipments, goods, or services, as
this causes the government to pay huge sums of money (Ruhnka et al,
2000). This is flawed pricing and it means that the government is
entitled to obtain a reimbursement.
Making a false bid claim is another case of Qui Tam. This entails the
provision of false information to the government regarding the cost of
certain projects being supported by the government (Ruhnka et al, 2000).
The aim of this is to get high profits from such projects. The
contracting organization is required to refund to the government the
extra money that was obtained through fraud in case it is found guilty.
Finally is false certification which involves the employment of
incorrect information with an aim of qualifying for specific benefits
provided for by the state. The advancement in technology in the current
times has resulted in the adoption of the same by health care
organizations and this has assisted them to manage health record for
patients. This is considered as fraud and it may subject an organization
to penalty if found guilty.
Procedure for Admission into a Health Care Facility that Upholds the Law
about the Required Number of Medicare and Medicaid Referrals
It is important for health care organizations to develop an admission
procedure for patients which comply with Medicaid and Medicare laws.
Doing so would help in preventing the various repercussions of Health
care Qui Tam. The first important factor which should be noted is that
Medicare supports inpatient persons only. This means that for a person
to benefit from Medicare, he/she has to have an acute illness resulting
to admission in the health care facility. Therefore, the first step is
for the general practitioner to carefully assess the patient with an aim
of determining whether or not inpatient services are required. After
this, the patient is referred to the case manage who evaluates the
patient’s records. The case manager also has the responsibility of
informing the hospital administration, the general practitioner, and the
patient in case such a patient qualifies to be admitted. Another
responsibility of the case manager is to document the reasons behind
such a judgment. After the admission, the next step involves the
assessment of the patient’s Medicare status by the case manager. The
duration of care is then determined and this is measured by the
condition of the patient as far as the illness is concerned. Reasons to
stay in the hospital are documented by the case manager. When the
condition of the patient improves to a point that justifies a discharge,
the same procedure is administered by the case manager who has the duty
of managing the billing procedure and reporting all the services
provided.
Corporate Integrity Program that will Mitigate Incidents of Fraud
Health care fraud is a rampant issue requiring attention. Fraudulent
providers usually put the welfare and health of beneficiaries at risk in
addition to costing taxpayers huge amount of money (Slade, 2000).
Individuals can play an essential responsibility in safeguarding the
integrity of the Medicaid and Medicare programs. This can be achieved
through the development of a corporate integrity program which can work
towards mitigating occurrences of fraudulent actions. In order to know
what to protect, it is paramount for individuals to be acquainted with
the things to watch for which may result in civil liability or abusive
practices. The recommended integrity program should involve training of
individuals including medical practitioners and hospital employees
regarding the requirements and rules of health care programs. The
training should focus on minimization of errors (recording and reporting
errors) documentation of transactions, admission, and discharge as
well as detection of fraudulent cases. The training program should also
focus on auditing of claims, contracts, and referral arrangements of the
organization. Through this, fraudulent cases would be detected without
difficulty and rectified before causing adverse impacts. Other factors
that should be included in the program are mechanisms to monitor the
activities of the organization, as well as disciplinary actions to be
taken against those found guilty of fraudulent acts. Proper
implementation of this integrity program would work in assisting
healthcare organizations mitigate fraudulent cases in addition to
improving such procedures as reproduction and birth.
Plan To Protect Patient Information
It is the responsibility of health care organizations to make certain
that patient information is kept confidential. According to the Centre
for Disease Control (2010) failure to ensure privacy may subject
organizations to legal action. To ensure proper protection of
information, the organization should devise a plan of accomplishing the
same. The plan should establish a security procedure that should be
followed by the entire staff members dealing with patients’
information. The portal should entail the identification of the patient
before any information is disclosed to prevent conveying the information
to the unintended person. The protocol should not allow the
organization’s staff to discuss information without any authorization
from the patient. Storage of the patients’ health records should also
be included in the protocol as this would prevent unauthorized persons
from accessing the same.
Conclusion
As aforementioned, health care fraud is a rampant issue requiring
attention. Through Qui Tam, the government has been able to deter
fraudulent activities linked with health care organizations. These types
of fraudulent cases encompass falsifying diagnosis codes by physicians,
intentional misrepresentation of information concerning the calculation
of capitated fee rates, billing for a similar service for over one time,
waiving of copayments regularly, as well as charging of healthcare
services that have not been provided. Some examples of Qui Tam cases
apparent in health care organizations encompass Medicare and Medicaid
fraud, false bid claim, false certification, and flawed pricing. Through
proper admission of the patients and development of a corporate
integrity programs, fraud can be minimized in organizations. As
discussed, privacy of patient information is also paramount.
References
Center for Disease Control (2010). Measures to Protect Patients
Confidentiality. Retrieved on September 13, 2013 from: HYPERLINK
“http://www.cdc.gov/tb/education/ssmodules/module7/ss7reading4.htm”
http://www.cdc.gov/tb/education/ssmodules/module7/ss7reading4.htm
Gumbert, J. G. (2003). Qui Tam Actions under the False Claims Act.
Medical Journal-Houston.
Mundy J. (2010). Health Care Fraud Qui Tam Lawsuits Net Millions for
Whistleblowers. Retrieved on September 13, 2013 from:
http://www.lawyersandsettlements.com/articles/qui-tam-whistleblower-gove
rnment-fraud/qui-tam-whistleblower-lawsuit-government-2-14190.html#.UFF6
UJN25uY
Ruhnka, J. C., Gac, E. J., & Boerstler, H. (2000). Qui tam claims:
threat to voluntary compliance programs in health care organizations. J
Health Polit Policy Law. 25(2):283-308.
Slade, S. R. (2000). Health Care Fraud: How Far Does the False Claims
Act Reach? Retrieved from
http://www.quackwatch.org/02ConsumerProtection/fca.html
The Department of Health and Human Services (2011). Medicare Fraud and
Abuse. Retrieved on September 13, 2013 from:
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNProducts/downloads/Fraud_and_Abuse.pdf
DEALING WITH FRAUD
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