Qui Tam: Suing Physicians Who Make False Claims - Research Paper Example

Qui Tam: Suing Physicians Who Make False Claims Introduction Qui Tam is the act or writ where an individual is capable to sue or prosecute a body under the name of the ruling government and is entitled to shares in the legal proceeds in case of any successful litigation or private settlement. Although generally punitive, it is seen as a civil procedure. The term Qui Tam is the shortened form of a well known abbreviated Latin phrase that translates to the term “he who prosecutes for himself as well as for the King” (Broderick, 2007, p.956, p.951). Before 1987, there was hardly any state which had formulated a false claims act or FCA having the provisions of Qui Tam. However, the situation presently is much different. After the enactment of the 1986 amendment for the FCA or the False Claims Act, there were eighteen states along with the District of Columbia who had enacted the Qui Tam legislation. Following this there were another nine states which had enacted similar bills in the legislatures of their country. After the enforcement of the sections 6031 and 6032 of the Deficit Reduction Act of 2005, the condition is expected to change in the countries. With regard to the enactment of 1986 amendment act for the FCA and accompanying the increased use of the legislations of the federal qui tam act, a good number of states have had enacted fraud detection laws or have been considering to enact their own false claims guidelines that would include the qui tam provisions (Broderick, 2007, p.956). Qui Tam regulations can be used across many disciplines. One such discipline is healthcare. Healthcare fraud is found to affect the patient severely by increasing the cost for health care as well as diminishing its quality. There are many cases of fraud and misinformation that the health care industry suffers from. If the person works for an organization that submits bills to any government oriented program such as the Medicare or Medicaid that includes blood testing laboratories, nursing care homes, ambulance companies, health care facilities, and others and if the person finds himself to be a victim of discrimination, job harassment or other frauds after detecting billing related frauds the person can sue the organization and seek reimbursements. Hence, the Qui Tam guidelines can be applied here which would help the harassed person in getting justice. Qui Tam can help to sue the physicians who make false claims and cause trouble to the patients. Fraudulent cases where the Qui Tam provisions can be used in the health care system includes increased billings for services where the service has not been availed, double billing where the same treatment like radiology- anesthesiology- pathology treatments are billed seperately, patient care quality which might be below par, certain services that might not be necessary for the patient but have been imposed by the physician and many more (Hsia, 1991, p.1050). According to the New England Journal of Medicine published on 5/13/10, 90 percent of the health care fraud incidents are controlled by the qui tam actions which are initiated by the whistle blowers acting on behalf of their respective government. From 1996 to 2005, the Qui Tam lawsuits generated more than $9 billion. Incidents in health care facilities where Qui Tam was used There are many incidents noted in the health care industry were huge amounts were paid as compensations to the aggrieved people by the fraud company often a health care unit. An Arkansas health care unit had agreed to pay $170 million as compensation including in several falsifications charges that included misinformation of the nursing logs where it was shown that the nurses of the heath care home had worked for a misleadingly higher number of working hours for nursing care to the Medicare patients who were shifted in the “Medicare distinct” beds. The fact was that there was no such extra work hours put in and the hospital nurses were looking after the Medicaid patients and the indigent or the private patients who paid separately. The regency hospital, LLC in Ohio and its subsidiaries had to pay a sum of $9.8 million in addition with the interest rates to resolve the false charges that were levied against them. The hospital group was charged for falsely charging the patients extra stay in the hospital by claiming that the average period for stay in the hospital was above 25 days (Levinson, 2010, p.20). In another incident, the City of Angels Medical Centre had agreed to pay 10.0 million dollars to settle their joint and various liabilities of allegations saying that the health care unit had conspired with different recruiters and paid sums to them for helping them acquire homeless people who were devoid of Medicare and Medi-cal benefits. Many unnecessary treatments which were not often required were performed on these patients (Levinson, 2010, p.21). In another fraud related case, Tennessee, Milan General Hospital was made to pay a compensation of $ 5.3 million for settling the civil allegation cases charged against it in between 1999-2003. The charge was that the hospital had admitted certain patients of the Medicaid facility in its psychiatric unit using improper means. After this the hospital had charged huge from Medicaid for the duration of stay of these patients which was beyond the coverage area of Medicaid (Levinson, 2010, p.21). Hendricks Community Hospital (Hendricks), Minnesota, agreed to pay $20,000 for resolving the liability cases for Civil Monetary Penalties that were charged under the patient dumping aspect. The OIG had alleged that the hospital had failed to conduct a medical examination and provide stabilization treatment to an individual who was referred to the emergency department of the hospital. The patient was known to have undergone surgery in a different hospital and was experiencing serious pain, was unable to urinate, and immediately required catheter placement. A physician from the emergency department had instructed the hospital staff to inform the patient that it would be beneficial for him, if he sought treatment from the hospital from where he had done his surgery. The hospital did not provide any screening or any form of treatment to the patient, despite of the fact that the patient was suffering from acute pain that made him difficult to ambulate. Admission into a healthcare hospital following physician’s referrals There are certain rules under the False Claims Act which govern the number of referrals in hospitals. The Physician Self-Referral Act that is also referred to as the Stark Law was been enacted to regulate and monitor the practice where a patient is referred to a health care unit for receiving a service where the consulting physician can have his own financial interest. There can be situations where a physician can be in a partnership with a hospital or a Magnetic Resonance Imaging (MRI) center. If the patient reports that he was referred to that hospital unit by the physician, the doctor can be charged for violating the Physician Self-Referral Act. A physician is allowed to only self-refer, and also prepare the bill of the patient if the referral unit comes under the purview of the eleven designated health care services under the Physician Self-Referral Act. This can be done only if the financial relationship of the physician satisfies any of the Stark’s law. These can be in the form of “in-office ancillary exception,” which permits the physicians to manage his/her own imaging centre, laboratory, and other form of ancillaries if the physicians form a collaborative decision to provide medical services in a group (Rodovsky, 1998, p.223). Corporate program for child birth and reproduction Fraud related incidents are rampant in the obstetric department in hospitals. Corrupt physicians and nurses tend to take advantage of this critical situation by exploiting the patients and their relatives. There can be occasions where proper care of the mother and the delivered child is not conducted properly. This can be dangerous not only for the mother but for the infant too. The corporate body of the health care unit needs to ensure that it checks these fraudulent practices in a timely manner. There can be incidents where the birth certificate is not prepared correctly, poor pre-natal care etc. The physicians need to be careful for birth injuries. These birth injuries can occur naturally but in most of the cases are caused by negligence of the doctors and the nurses. Sometimes the doctors might feel that they need to intervene in the normal birth process to relieve the birth pain or are in a hurry to complete the process. These can be natural which means the patient needs doctor intervention but can be fraudulent also where the doctor might create an artificial situation to rake in some profits. There can also be cases of negligence due to shortages of staff and poor treatments. The hurrying tendency of the doctor to complete the birth process can lead to complications like dystocia as well as birth injuries such as cerebral palsy. A health care unit has to be very cautious while handling such matters. It has to be careful while conducting the deliveries through cesarean section. C- Sections are very risky as there are chances for the mother to get injured during the operation which can harm her reproductive capacity in future. There is a high probability for hysterectomies in these patients. The conditions mentioned above are natural cases but sometimes some fraudulent behavior can also be seen. These can be in the form of an induced C-Section operation where the patient might be in the condition to deliver the child normally. Sometimes the surgical equipments and the care needed after child birth are of poor qualities which are dangerous in obstetric. The hospital’s corporate body needs to address these issues in their planning. Protecting the patient information Protecting the patient’s information is one of the essential parts for maintaining the trust of the patient. It is a duty of the hospital to maintain all the information of its patients in a confidential manner. The hospital can include several strategies and plans to protect the confidentiality of the information. Healthcare officials can frame measures in order to protect the confidentiality of the patients anywhere. In a general situation, there are some important measures that the health care worker can adopt for protecting the patient confidentiality: He must confirm the identity of the patient the very time the patient is admitted in the hospital. He must never discuss any matter related with the patient's case without his permission that would include his family as well as friends. He must never leave any hard copies of the forms or any record where an unauthorized person can access them. He must use only trusted routes for sending patient information such as an official mail and should always mark the mail as confidential. High level of care needs to be taken to protect the patient confidentiality in places like the office. The concerned person can take the following steps to protect the patient information in these places: The patient interviews must be conducted in private places and the name of the patient must never be disclosed in public. The staff member must establish their respective designation and authority before requesting patient information. The person can further help to protect the confidentiality of the patient by taking help of data management processes. The person taking care of the information or the hospital keepers must keep the records of the patient containing the patient names, address etc in closed, locked enclosures or files. The hospital must restrict any sort of access to the electronic databases. They must preserve the computer passwords or the keys. The computers must be kept locked or in restricted areas. The printouts must be kept in restricted areas. Conclusion The provisions in Qui Tam allow any private citizen to conduct a civil action under the name of his native government. There are many fraudulent practices that can be seen in the hospital care units. These are not in the good interest of the patients as they harm them both physically and financially. As such the qui tam laws have been enacted to make it mandatory for the hospitals to maintain truthful and legal behavior. This is particularly essential in the obstetrics department where fraud related cases are high. Using Qui Tam regulations the patient will have the authority to sue the hospital bodies and ask for compensations according to the situations. References Broderick, C. O. (2007). QUI TAM PROVISIONS AND THE PUBLIC INTEREST: AN EMPIRICAL ANALYSIS. Columbia Law Review, 107( 4), 949-1001 Hsia, D. C. (1991), Qui Tam: Suing Physicians Who Make False Claims. Annals of Internal Medicine, 114 (12) Levinson, D. R. (2010), Health Care Fraud and Abuse Control Program: Annual Report for Fiscal Year 2009. DIANE Publishing Quui tam- the false claims act and related federal statutes Doyle, C., ( 2009). Retrieved from http://www.fas.org/sgp/crs/misc/R40785.pdf Rozovskys, F. A. (1998), Corporate Compliance in Home Health: Establishing a Plan, Managing the Risks. Aspen Pub Read More