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 entertainment.
The offer, payment, solicitation or receipt of any such monies or remuneration can be a violation of the Federal Anti-Kickback statute, 42 U.S.C. §1328-7b(b), the Federal False Claims Act, as well as various other federal and state laws and regulations. Ghost Patients: The submission of a claim for health care services, treatments, diagnostic tests, medical devices or pharmaceuticals provided to a patient who either does not exist or who never received the service or item billed for in the claim. Up-Coding Services: Billing of government and private insurance programs is done using a complex series of numerical codes that identify the specific procedure or service being performed.
These code sets can include: the American Medical Association’s Current Procedural Terminology (“CPT”) codes; Evaluation and Management (“E&M”) codes; Healthcare Common Procedure Coding System (“HCPCS”) codes; and International Classification of Disease (“ICD-9”) codes. Government health care programs assign a dollar amount it will pay for each procedure code. Up coding occurs when a health care provider submits of a claim for health care services, treatments, diagnostic tests or items that represent a more serious and more expensive procedure than that which actually was performed.
Up coding can be a violation of the Federal False Claims Act. Bundling and Unbundling: In many cases, government health care programs have special reimbursement rates for groups of procedures that are typically performed together, such as laboratory tests. One common type of fraud has been to “unbundle” these procedures or tests and bill each one separately, which results in greater reimbursement than the group reimbursement rate. Attorneys in the national qui tam whistleblower practice of Pietragallo Gordon Alfano Bosick & Raspanti successfully represented the lead relator in one of the largest cases of “unbundling” in the history of false claims litigation, United States ex rel.
Merena v. Smithkline Beecham Clinical Labs, which resulted in a recovery of $328 million for federal taxpayers. False Certification: When physicians, hospitals and other health care providers submit bills to government health care programs they are required to include a number of important certifications, including that the services were medically necessary, were actually performed, and were performed in accordance with all applicable rules and regulations.
Additionally, health care companies such as pharmaceutical companies and pharmacy benefits managers that provide products or services to government health care programs are required to certify that they are satisfying all obligations under their contracts with the government. One common type of fraud has been to falsify these certifications in order to get a health care claim paid or to obtain additional business” (Raspanti, n.d.). Stanton (2001) acknowledges that in a healthcare facility, with Medicare, each false claim is considered an individual billing whether for a specific medical item or service.
Penalties can rise quickly with suspension or delay payment of future claims for a facility if it has been accused of submitting false claims (Stanton, 2001). Devise a procedure for admission into a health care facility that upholds the law about the required number of Medicare and Medicaid referrals.
In order to avoid health care qui tam, healthcare organizations must stay abreast and compliant with Medicare and Medicaid laws. When a patient enters a facility for illness or an appointment, there are steps to follow. At check-in, the patient gives insurance card and pertinent information to nurse. The nurse enters the information into the system.
The patient waits for the doctor to assess the illness to determine the needs of the patient. “Physician inputs information into the system and system codes the treatment based on Medicare or Medicaid protocols; system confirms and red flags any treatment or medication that is not allowed; patient is discharged and Medicare or Medicaid is billed for services rendered by the hospital, physician, and for medication” (Burnaby, Hass, & O’Reilly, 2011).
If for some reason, items billed are questioned or denied, the items are reviewed and resubmitted to Medicare or Medicaid for payment. Recommend a corporate integrity program that will mitigate incidents of fraud and assess how the recommendation will impact issues of reproduction and birth.
Corporate Integrity Agreements (CIAs) are considered second chances for healthcare organizations. By using CIAs, the organization avoids exclusion from Medicare, Medicaid, or other Federal healthcare programs by establishing and implementing a compliance program per CIA regulations and guidelines (MetricStream, n.d.). Implementing CIAs is challenging and can cause financial strain; however it can “protect stakeholders and customers from risk, and build brand value” (MetricStream, n.d.) CIAs are implemented for healthcare organizations to uphold certain standards and to fulfill the organizations’ missions and goals.
CIAs are usually proposed due to allegations of fraud or abuse which are found to be true through audits or self-disclosures; and are drawn up for a period of three to five years and can extend up to eight years (MetricStream, n.d.).
Ramsey (2002) suggests that a recommended integrity program should include stipulations such as “designation of a compliance officer and a compliance committee” – to ensure that the needed changes will be made; “a required code of conduct, mandated compliance policies and procedures” – stating that the organization is committed to complying with the laws; “training requirements” – to ensure that staff and physicians are knowledgeable and up-to-date on all requirements and processes required by the organization, the government and vendors; “review and auditing procedures” – to help reduce errors when reporting claims; and a “confidential disclosure program where employees internally may report possible violations of the law” .
Once a CIA is implemented, to deter employees from committing fraud, a stern disciplinary action process should be enforced and followed. Devise a plan to protect patient information that complies with all necessary laws.
Protecting patient information is a responsibility of all healthcare organizations and a plan or process must be in place to do so. In any situation, whether in an office, clinic, or in the field, there are important procedures that can be followed to protect a patient’s information and confidentiality (Centers for Disease Control and Prevention, 2012).
As a health care worker, you must “confirm the patient’s identity at first encounter, never discuss the patient’s case with anyone without the patient’s permission, never leave hard copies of forms or records where unauthorized persons may access them, and use only secure routes to send patient information and always mark confidential” (Center for Disease Control and Prevention, 2012).
When in healthcare settings “conduct patient interviews in private rooms, never discuss cases or use patient’s names in public area, and always obtain patient’s permission before distributing his/her information to a staff member or healthcare worker” (Center for Disease Control and Prevention, 2012). Always keep medical records and computers used in a locked or secure box to prohibit unauthorized persons access. Creation and implementation of a protection and privacy plan can reduce legal actions under the Health Insurance Portability and Accountability Act.
Qui Tam cases impact healthcare organizations in various ways to include high penalties if found guilty, payback of monies received, and a negative image for the organization. Medicare and Medicaid fraud cases are the most common qui tam cases. In order to reduce fraud and abuse cases, healthcare organizations must improve their current admission procedure, their corporate integrity program, and their patient information protection system.
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