Dealing with Fraud

Last Updated: 27 Jan 2021
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Dealing with Fraud Health Care Policy, Law, and Ethics HSA 515 March 09, 2013 Dealing with Fraud Obstetric health care centers are a major source for providing care to millions of women around the country and a branch of medicine that involves pregnancy and childbirth. Studies of pathologic and physiologic functions of the female reproductive area are also a part of obstetric care. Physicians in this field commonly referred to as OB/GYNs and care for the mother and fetus during pregnancy. As Chief Nursing Officer of one of the state’s largest Obstetric Health Facilities countless women are treated at this center.

The staff is fully aware of the mission, vision, policies, and procedures that make a huge impact in the community. Women rely on the care and attention received from the exceptional physicians on staff. Unfortunately, the type of care delivered and the service the hospital is responsible for providing, word of fraudulent behaviors have been reported and must be addressed. As United States health care cost continues to rise, people depend upon privately funded health plans and millions are still uninsured due to funding by state and federal government.

The major government sponsored health care plans are Medicare and Medicaid programs. Both programs make up a large portion of government spending. One key reason for rising costs has been the enormous degree of fraud committed against government health care programs. Although billions have been exposed due to informants of qui tam, additional monies remain undetected. Ultimately, health care fraud used as a deceptive means to profit from health care agreements through the federal government and the reason the United States Government Accounting Office has categorized Medicare and Medicaid as “high-risk programs. Various sources evaluate the effect of qui tam in health care organizations and refer to the 1986 False Claim Act the effectiveness. The term “whistleblowing” recognized by provisions in the False Claims Act and authorizes cases be brought to the government on behalf of the United States to share in the recovery efforts. The “Informer’s Act” or better known as “The Qui Tam Statue is from the Latin phrase “qui tam pro domino rege quam pro seipse,” meaning “he who as much for the king as for himself,” established during the civil war and focused on ending dishonest suppliers to the union military.

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Therefore, fraud investigation, and legal action became easier for the government. The history behind qui tam statue and today’s use provides an understanding to the term “whistleblower” and for an individual with past or present knowledge of fraud on the federal government to recover damages and impose penalties, (Cruise, “n. d. ”). Fraudulent behavior or health care fraud affects health care organizations. Several ways businesses and individuals have defrauded, and continue to defraud, federal, and state government health care programs.

Examples of fraudulent behavior include: • No Services: Non-submission of claims for diagnostic tests, treatments, devices, or pharmaceuticals services that were never rendered. • Non Existence: Involves submitting a claim for the services previously mentioned and provided to patients that do not exist or never received service. Also an item billed for in the claim. • Anti-Kickback Statute: bans any offer, payment, solicitation or receipt of money, property or remuneration to persuade or reward patient referrals or health care services funded by a government health care program, including Medicare or Medicaid.

These are improper payments and come in several different forms, includes but not limited to: referral fees, finder’s fees, productivity bonuses, research grants, 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 USC §1328-7b(b), the Federal False Claims Act, various other federal, state laws, and regulations, (Pietragallo, Gordon, Alfano, Bosick, and Rapti, LLC, 2013).

These are just a small number of fraudulent activities currently affecting health care organizations. Qui tam has been an effective force in combating fraud. The Justice Department continues to recover record amount of judgments and settlements, however, qui tam cases exist in a variety of health care organizations. Processing and payment errors of Medicaid and Medicare patients may appear to be simple mistakes and not by medical professionals attempting to take advantage of the system, but individuals intent on abusing the system particularly, with working nowledge of how and when the government pays Medicare and Medicaid claims. Also in some cases fraud affects the people with these programs and liability occurs for co-payments and contributes to excessive government spending. Other examples of qui tam cases include; Defective pricing/false negotiation – reflects price adjustments by submitting false data and pricing to the government to receive an inflated amount according to the contract price. Mischarging – one of the more widespread frauds used to submit claims for products or services never provided or rendered.

Product/service substitution – A product is certified that does not meet specifications or submitting a product for government approval then substituting the merchandise with another of poorer quality. False certification – benefit entitlement documents are falsely certified. Information submitted to the government has been adjusted for price supports or mortgage guarantees, according to the source more than half of qui tam recoveries have involved health care fraud, qui tam lawsuits filed have been successful against defense contractors and other companies, ("Einstein Law," 2008).

Various federal and state requirements must be satisfied by the health facility prior to admission. For example, pre-admission evaluations for Medicaid patients require prior determination for eligibility. A full patient assessment will determine a plan of care. The prescribed care plan is prepared by the attending physician and registered nurse. Other hospital staff will get involved with the patient’s care if necessary. The care plan is updated on a quarterly basis, or more frequently if the patient’s condition changes.

Other requirements for Medicare and Medicaid patients must be met before admission to determine suitable environment and to respect patient’s rights after admission while receiving medical care. Procedures for admission into a health facility for Medicare and Medicaid referrals must understand and comply with the laws that govern these procedures. The Anti-Kickback Statute (“AKS”) enacted by Congress delivers criminal penalties for the payment of fees designed to persuade or reward medical referrals for treatment covered by Medicare and Medicaid.

The AKS is extensive and includes discounts for physician referrals. Liability is a major concern under the Anti-Kickback Statue unless procedures fall within the law. Another regulation that limits physician self-referrals for Medicare and Medicaid patients is The Stark Law. Hospitals or health care providers are prohibited from receiving payments or kickbacks after improper billing Medicare for selected equipment or services. Ultimately, claims cannot be submitted by physicians for items or services because of their financial relationship with the health care providers.

The Stark Law passed because of inappropriate financial relationships between doctors and health care providers and the professional judgment of doctors with regard to whether items or services are medically necessary, safe, or effective also reduce probable overpayments by Medicare for uncertain services, (The Qui Tam Team, 2012). The next stage is for physicians and nurses review the following conditions for patient referrals. 1) Services must be personally referred by the attending physician. 2) Referrals are to a physician of the same group or practice. ) Any individual supervised by the referring physician in the hospital or physician that works part-time in the facility and is part of a group practice must comply with all coverage and payment rules regarding Medicare and Medicaid patients. 4) Patient billing is by the physician performing or supervising the care and treatment of the patient. 5) Regarding a group practice, attending physician under the group must be a member with an assigned billing number different from physicians employed with the health facility. ) Third party billing companies representing the physician(s) will also be assigned a billing number. These companies have to comply with Medicare requirements. The task of evaluating referral arrangements by physicians will be challenging, however: financial provisions involving physicians can be analyzed using the conditions outlined. The Chief Nursing Officer will receive a monthly report of Medicare and Medicaid referrals. Non-compliance will result in immediate termination from the health facility. Discussing fraud and abuse the health industry continues to lose billions.

Fraud can range from performing unnecessary medical procedures for insurance gains, to altering patient information and illegally billing for services not rendered. Also accepting kickbacks for patient referrals, and promoting drugs without authorization. These incidents affect the economy and are potential hazards to the health and safety of patients. An example is medical information illegally altered may receive incorrect treatment or realize existing health benefits are exhausted. Either way another alternative for compliance can address these issues.

A method of enforcement created by the office of the Inspector General (OIG) identified as a Corporate Integrity Agreement to improve health care quality and promote compliance to health care guidelines. The term “Integrity Agreement” focuses on physicians according to one source. Establishing OIG 1976 to imposed action against widespread fraud and abuse in Federal health care programs. These efforts developed a collaborative use of enforcement tools as monetary penalties and exclusions. Corporate Integrity Agreements implemented by the OIG to redeem health care providers under the program to avoid exclusions.

Implementing a CIA will be challenging and somewhat complex, especially for birth and reproduction. The sterilization process, wrongful birth, and wrongful life are areas of interest, and the CIA will have major impact. Physicians play a major role due to misconception by prenatal testing, genetic testing, and laboratories that failed to provide these services. Sterilization falls under reproduction and birth is another area likely for fraudulent behavior from the side effects patients go through and were not informed by the attending physician.

Nevertheless, to address current fraud behaviors and prevent future incidents among physicians, nurses, and medical staff it is necessary to develop strategies to ensure ethical and moral business practices through compliance of various laws that will reduce any risk of legal liability. Although the CIA program contains various features, after careful review and collaboration among executive staff the following requirements will accommodate the needs and requirements that will mitigate incidents of fraud by: Developing written policies and standards;

Instituting a confidential disclosure program; Employing a compliance officer or a compliance committee; Implementing an employee training program; Restricting employment of ineligible persons; Report overpayments, fraudulent behaviors, and ongoing investigations/legal proceedings; Implementation reports are provided annually to the regulatory agency, (Sable, 2013). These requirements should prevent future fraud misconduct by ensuring internal actions and mitigating methods are in place. In conjunction with fraud and abuse is protecting patient information and omplying by all applicable laws. Accessing patient information considered a major subject for health organizations to comply with the Health Insurance Portability and Accountability Act (HIPPA) laws. Patient medical records are vital for treatment and must remain confidential within the federal and state laws. Without authorization the patient Privacy Rules are in violation. The responsibility of Chief Nursing Officer ensures the medical staff training and knowledgeable of health center’s policies and procedures to remain in compliance with HIPPA.

Often areas overlooked whether accidental or intentional and certain information is discussed or discarded documents. Routine conversation among staff would be limited to specific areas where patient information cannot be disclosed. Public areas such as elevators, hallways, or waiting areas are strictly off limits. Many times patients are in surgery or receiving treatment for an illness, family members are waiting for results and often physicians will meet with them in public areas to discuss sensitive information not realizing the conversation can be overheard by others. This is just one example of a disclosure violation.

Also what may sound insignificant represents another action that can lead to breach of information by patient documents thrown in a trash can that must be shredded to avoid public view. The plan is simple; to comply with all necessary laws extensive training provided to the entire staff is the beginning. One-on-one and group meetings held on a quarterly basis as a tool to prevent abuse and fraudulent behavior. Patient sensitivity is essential in meeting the goals of health center. Laws provide direction for dealing with fraud cases or any unethical or moral decisions made.

To eliminate fraud and abuse continued pressure on the government to establish tougher policies in the delivery of medical and health care services. Additional funding for government enforcement agencies will put more pressure on physicians to act responsibly. As physicians become more aware of this fact, he or she should continue to take steps, such as implementing a compliance plan, to ensure the services provided reflect effective documentation for claims of payment. Until doctors, nurses, and other medical staff demonstrate ethical and moral standards, fraud, and abuse will continue to a problem for health organizations. References

Fraud and Qui Tam Cases. (2008). Retrieved from http://www. lawyershop. com Healthcare Fraud and Qui Tam Suits. (2008). Retrieved from http://www. lawyershop. com Pietragallo, Gordon, Alfano, Bosick, and Rapti, LLC. (2013). Health Care Fraud and False Claims. Retrieved from http://www. falseclaimsact. com Cruise, P. L. (“n. d. ”). Deregulating Health Care Ethics Education. Retrieved from http://www. spaef. com/article Sable, L. (2013). Negotiating Corporate Integrity Agreements. Retrieved from http://www. franchiselawsolutions. com The Qui Tam Team. (2012). Types of Qui Tam Cases. Retrieved from http://www. quitamteam. com

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Dealing with Fraud. (2016, Dec 27). Retrieved from

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