Dealing with Fraud
By: Kevin McCarthy
To: Dr. Michelle Rose
HSA 515 Health Care Policy, Law, and Ethics
December 13, 2012
As the Chief Nursing Officer, I am responsible for one of the state’s largest Obstetric Health Care Centers. I have received word of some fraudulent behaviors in the center. I will evaluate how the Healthcare Qui Tam affects health care organizations. I will provide four (4) examples of Qui Tam cases that exist in a variety of health care organizations. I will devise a procedure for admission into a health care facility that upholds the law about the required number of Medicare and Medicaid referrals. I will recommend a corporate integrity ...view middle of the document...
If the government decides to take over the case, the relator will receive 15 to 25 percent of the amount recovered. If the government declines, the relator may still pursue the matter. If successful, the relator will receive up to 30 percent of the recovery (Showalter).
The federal government’s main weapon in the “war” on fraud and abuse is the civil False Claims Act (FCA). This federal statute provides that a person is liable for penalties if he: 1) knowingly presents, or causes to be presented, to an officer or employee of the United States a false or fraudulent claim for payment or approval, 2) knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the Government, 3) conspires to defraud the Government by getting a false or fraudulent claim allowed or paid, or, 4) knowingly makes, uses, or causes to made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the government (Showalter).
These standards require health care providers, and their top management and governing board members, to have mechanisms in place to verify the accuracy of their organization’s claims. A further incentive to comply is the threat of exclusion from participation in Medicare and Medicaid (Showalter). The government may exclude from participation any individual who, 1) has a direct or indirect ownership or control interest in a sanctioned entity and has acted in deliberate ignorance of the information, or 2) is an officer or a managing employee of a convicted or excluded entity, irrespective of whether the individual participated in the offense (Showalter). Any excluded person who retains control or continues to serve as an officer or a managing employee in such entity may be fined $10,000 per day. This threat and the potential for criminal convictions and massive fines have been the major forces motivating health care organizations to adopt corporate compliance programs (Showalter).
Provide four (4) examples of Qui Tam cases that exist in a variety of health care organizations
Medicare and Medicaid fraud have cost the federal government billions of dollars. Qui tam lawsuits filed under the False Claims Act (FCA) have been responsible for some of the government’s biggest health care fraud recoveries (Phillips). There are many different ways companies can bilk Medicare and Medicaid. The examples of health care fraud that I will discuss give an idea of the types of fraud that have been or could be the basis of qui tam (whistleblower) lawsuits (Phillips).
Services not rendered/add-on services is possibly the clearest example of fraud by health care providers. It involves billing for services that were never delivered to the patient. The basic scheme is to involve as many variations as there are treatments. For example, some physician’s bill Medicare or Medicaid for diagnostic procedures they never performed,...