Fraudulent Practices In A Healthcare Sphere - Research Paper Example

Fraudulent Practices In A Healthcare Sphere Health care fraud comprises of professional crime that entails filling of dishonest claims in healthcare facilities in order to convert them into profit. Basically, fraudulent healthcare schemes occur in numerous forms. For instance, billing for an uncovered service as a covered service, intentional incorrect reporting of diagnoses or procedures in order to maximize a profit, alteration of dates, among other fraudulent behaviours (Busch, 2008). Of most important is that once these fraudulent practises have penetrated in a healthcare centre, then subsequent costs are passed along to the patients. In light of this, state’s largest Obstetric Health Care centre has become a victim of fraudulent behaviours where the Chief Nursing Officer is in charge (Greenwald, 2010). How Health Qui Tam Affects Health Care Organizations Apparently, Qui Tam denotes any legal action that private individuals take in place of the government and individuals themselves in relation to an entity such as Obstetric Health Care centre that is alleged to have acted against the government rules and regulation as they conduct their daily business with the government, over and above, other entities. Of importance to note is that those individuals who decide to fill quit tam are likely to receive substantial sum of money retrieved from the particularly entity that has alleged being said to commit fraud hence a defendant at a legal entity (West, 2000). In a general sense, the legal action is mainly applied in cases where excessive violation of rules and regulation has been discovered. It is worth noting that the Obstetric Health Care centre and other health care institutions have numerous transactions that they conduct with the government such as making claims for the services that are given to Medicare and Medicaid patients. In light with Health Qui Tam law, private individuals have been given the responsibility to chase and track down the recovery of funds from health facilities that engaged themselves in fraud and have moved further to place claims on the United States government so as to received disputable compensation. In respect to this, the Health Qui Tam has adverse impacts on health facilities’ and organizations. To begin with, health facilities’ that have involved themselves in fraud risks financial losses especially when they are found guilty of fraud. In essence, health facilities that are found guilty of committing fraud might be expected to make a full repayment of the substantial amount of money that they have illegally got from the government through disputed compensation. Moreover, the health facilities might also be required to pay a substantial amount of fine to the Civil Money Penalty (CMP) in relation to the degree of penalty they have committed. Apparently, the CMP may compel the said organisation to pay a fine, thrice the amount of money they were alleged compensated. Through this action, alleged organizations suffer financially, as well as, in terms of their corporate image. Thus, the Chief Nursing Officer at the Obstetric Health Care should be advised on the impact the fraudulent dealing will cause to the health facilities in case there is poor management (Boese, 2011). Examples of Qui Tam Cases That Exist In a Variety of Health Care Organizations There are numerous Qui Tam cases of fraudulent cases that exist in various organizations particularly in the United States of America. Of importance to note is that most of the cases revolve around Medicare and Medicaid fraud, a situation that qualifies for Qui Tam. In addition, some health facilities have been known to cause false bid claim that involves the provision of inaccurate information on certain health projects with the government, flawed pricing that comprise submission of overstated prices particularly when they are negotiating certain contracts with the government, false certification where there is use of false information so as to qualify for certain benefits that are given by the government or state. West 2000 argues that the Qui Tam lawsuits have continually made it possible for the government to recover substantial sum of money received through fraudulent claims. First Fraud Case One particular case that was brought under the federal False Claims Act (FCA) entails Mylan, Inc is said to have agreed to pay $57 million to settle allegations based on causing California and the federal government to overly pay for drugs that were meant to benefit California’s Medicaid program. According to Boese 2011, the Qui Tam private individual who gave out the information is legally responsible to receive around $8.5 million that clearly showed that both the powerful financial inducement for the private individual who blew the whistle about the case, over and above the sophistication of the individual or entity that gave information about the case, and those who were involved in filing the suits. Of importance to note is the private entity, Ven-a-Care is estimated to have made known over two dozens of Qui Tam lawsuits in a decade where they have collected around $ 400 million from the proceeding that have emanated from all these cases. Second Fraud Case Still under False Claim Act (FCA), fourteen hospitals in several states are alleged to have agreed to pay around $12 million to resolve a case where they were accused of submitting bogus accusations to Medicare by carrying out kyphoplasty activities that comprise of treating spinal fractures on an inpatient basis when there was an opportunity to perform the procedure in a safe manner using a lesser cost especially through outpatient procedure. In general, this settlement concluded with 40 hospitals to a total of $ 39 million (Boese, 2011). Third Fraud Case In regard to individuals, the Assistant Dean for Medical Affairs (Temple University School of Medicine), Dr Joseph. J Kubacki was jailed for 87 months and required to pay close to $1.1 after being found guilty of over 150 counts of health care fraud, wire fraud and further making false statements in relation to health matters. In essence, Dr. Kubacki conviction resulted from a health care fraud scheme where he is alleged to have given in fraudulent allegations, which led to more than $1.8 million to be compensated by Medicare and 31 other health insurers. In fact, the period between 1996 and 2007 he managed to cause thousands of claims that totalled to $ 4.5 million in regard to the services that were offered to patients that he did not have any credible information about. (McWay, 2003). Fourth Fraud Case Another fraudulent case revolve around an ambulatory cardiac telemetry (ACT) company LifeWatch Services, Inc that is noted to have agreed to pay the United States of America around $18.5 million in a bid to resolve the allegations that were brought forward in relation to two Qui Tam law suits where LifeWatch billed Medicare for ACT monitoring services to patients who were no illegible for the services. Besides the monetary compensation, Life Watch was compelled to enter into five years Corporate Integrity Agreement and HHS’s Office of Inspector General (OIG). In light of this, CIA expected LifeWatch a broad fulfilment program where there would be thorough monitoring and reporting responsibility for the agreed period of time. McWay 2003 articulates that it is crucial to understand that most of these are some of the infamous issues in health facilities that have dominated this section for the past several years. It is evident that these and other cases have declined their images of the alleged companies and individuals. Needless to mention, there is the presence of hefty fines from the lawsuits, over and above, consistence financial fatalities. Devise A Procedure For Admission Into A Healthcare That Upholds The Law About The Requires Number Of Medicare And Medicaid Referrals Health facilities and organizations are some of the fraternities that require high professionalism and in particular when they are dealing with their clients (patients) who come into the facilities with varying issues. In light of this, the Obstetric Healthcare centre that is overseen by the Chief Nursing Officer, it is indispensible to come up with a procedure for admission of patients, one that upholds the law in relation to the number of Medicare and Medicaid referrals (Greenwald, 2010). To begin with, patients’ admission should be conducted by physicians after they have assessed the patients to ascertain whether the illnesses they are suffering from are acute or whether they require inpatient services. Of most importance is that Medicare kits specifically target patients who need inpatient services. Secondly, physicians are then expected to refer the patients’ cases to the Chief Nursing Officer, who then re-examines the records to establish whether the patients’ require inpatient services. In the occurrence that the patient requires inpatient services then the physicians, the patients and hospital administrations should be informed. Thirdly, once the inpatient services are confirmed, the Chief Nursing Officer moves in to evaluate the Medicare statues in relation to individual patients. Fourthly, the physicians ought to determine the duration of care. If anything, the Chief Nursing Officer and the physicians go into consultation with regard to the period of time the patients are expected to stay in the health facility with reference to the condition of the patients as the Chief Nursing Officer continuously documents the reason that have kept the patients in the facilities. Once, the patients are ready for discharge the Chief Nursing Officer should ensure that she supervises the process of billing to avoid the occurrence of fraud at any part of the of the admission procedure (Greenwald, 2010). It is worth noting that, every hospital management must be in a position to document the reasons for admission of all patients in the inpatient services. None the less, patients who require minor treatments that take 24 hours or less, should be treated as outpatients who do not need Medicare reimbursement. Through this, it is certain that the fraud will automatically reduce at the health care centre, a situation that translates to financial stability and a good public image for the health care centre (McWay, 2003). Recommend A Corporate Integrity Program That Will Mitigate Incidents of Fraud and Assess How the Recommendation Will Impact Issues Of Reproduction and Birth Notably, a healthcare centre that specialises with childbirth and caring for pregnant women in connection to child birth, corporate integrity program is necessary as it assists in mitigating incidents of fraud. In light of this, a training program for physicians and other hospital staffs in relation to rules and requirements of Medicare and Medicaid will ensure that inaccuracy that are susceptible to occur in instances such as reporting of claims, over and above, ensuring that all the members of staffs in the health facility are in a position to identify case of fraud before they occur. In addition, the health facility should allow for regular audit on claims, contracts, as well as, referral arrangement to ensure that fraud cases are easily discover and rectified preceding to result in adverse effects. The training program should put emphasis on having clean transitions especially through proper documentation. It is professional to offer written documentation in relation to the entire admission procedure that the health centre engages itself in. Basically, this documentation will serve as a proof that health care centre is continuously abiding by the rules of law. The health facility should come up with stringent measures for those members who are found guilty of fraudulent engagement within the facility thus discouraging them from such illegal deeds. Apparently, these recommendations guarantee patients who have issues of reproduction and child birth good healthcare coverage in relation to treatment and finances. In a general sense, patient will be entitled to Medicare once they are admitted for child birth, over and above, assurance of having proper record of their continuous stay in the hospital. Devise a Plan to Protect Patient Information That Complies With All Necessary Laws The protection of patients in the medical fraternity is an obvious issue. In fact health care organization are mandated to give privacy to the patient information, failure to which legal action could be taken against them (Busch, 2008). In respect to this, Obstetric Health Care should come up with a security strategy where staff members who handle information from patients are expected to abide. In this security strategy, the employees are compelled by the facility regulation to confirm the identity of patients by issue of the Social Security Number before revealing information as it ensures the employees do not give information to the wrong people (Greenwald, 2010). Of most important is that the plan should develop a security storage protocol such as a Password or Lock and Key for the medical records so that unauthorised persons do not get access. Needless to mention, secure channels should be utilised in conveying patient information. Conclusion Health care fraud comprises of professional crime that entails filling of dishonest claims in healthcare facilities in order to convert them into profit. Basically, fraudulent healthcare schemes occur in numerous forms. Apparently, Qui Tam denotes any legal action that private individuals take in place of the government and individuals themselves in relation to an entity such as Obstetric Health Care centre that is alleged to have acted against the government rules and regulation as they conduct their daily business with the government and other over and above other entities. There are numerous Qui Tam cases of fraudulent cases that exist in various organizations particularly in the United States of America. Of importance to note is that most of the cases revolve around Medicare and Medicaid fraud, a situation that qualifies for Qui Tam. Thus, Qui Tam has an effect on health organizations. References: Boese, J. (2011). Civil False Claims and Qui Tam Actions. Austin [Tex.]: Wolters Kluwer Law & Business, Aspen Publishers. Busch, R. (2008). Healthcare Fraud: Auditing and Detection Guide. Hoboken, N.J.: John Wiley & Sons. Greenwald, H. (2010).Health Care in the United States: Organization, Management, and Policy. John Wiley & Sons McWay, D. (2003). Legal Aspects of Health Information Management. Clifton Park, NY: Thomson/Delmar Learning. West, R. (2000). Qui Tam Whistleblower Litigation. Chicago, IL: American Bar Association. Read More