Evaluate How the Healthcare Qui Tam Affects Health Care Organizations

Dealing with Fraud

Narkeisha Bryant

HSA 515 - Health Care Policy, Law, and Ethics

September 9, 2012

Evaluate how the Healthcare Qui Tam affects health care organizations.

Health care fraud is something of a white-collar crime that involves the filing of dishonest health care claims to turn a profit. Fraudulent health care schemes are bilking the systems of billions of dollars, driving up the cost of health care for all Americans. The high cost of fraudulent claims has given rise to fraud investigation, whereas the United States Government is looking at health care providers. Hospitals, laboratories, health maintenance organizations, and doctors' offices are being targeted for investigation. As the Chief Nursing Officer of the largest Obstetric Health Care Center in the states, there is a duty to evaluate the Qui Tam affects on health care organizations and provides examples of Qui Tam cases that exist within a variety of health care organizations.

Qui Tam, a provision of the Federal False Claim Act of 1986 which, legally permits citizens to file suit under seal on behalf of the United States Government, to recover monies lost to fraud (Barger, (2011). Qui Tam can be file against any individual or organization that fraudulently misuses government funds. Qui Tam entitles the citizens who filed suit - called a whistleblower - to collect a share of whatever funds are recovered (Barger, (2011). The person who makes the accusation of suspected fraud is known as the relator. Relator or whistleblowers are current or former employees of the health care organization and portray a major factor for presenting fraud attention to the federal government.

Whistleblowers have provided creditable information regarding false claims submitted to Medicare and Medicaid. Suit of this nature can result in damages and penalties that have a tremendous effect on health care organization, but can result in a significant reward for the whistleblower under certain conditions of the government's recovery. Additionally, whistleblowers are serious protected against retaliation by his or her employer under the False Claim Act, which includes reinstatement or lost compensations. The government has used False Claim Act to investigate health care providers from managed health care organizations, clinical laboratories, physician practices, and home health care organizations. Despite unselfish goals, whistleblowers are experience substantial hardships on both a personal and professional level. Among all current federal health care fraud case 90% of them are "qui tam" actions, which present direct knowledge of the alleged fraud by initiate litigation for the federal government and then go on to serve as active participant in the cases (Androphy, 2010). Qui tam actions have led to billions of dollars of Medicare and Medicaid fraud recovering in recent years. Such actions are publicized as cost-effective and may dissuade inappropriate behavior, but little knowledge is formed on how the process works. Health care organizations that treats Medicare and Medicaid recipients has found that the risk of fraud violation has increased and pose a potential threat to the health care system. Improving the management and overall outcomes of fraud claims harbors significant financial advantages for health care organization.

Health care organization must provide a dynamic regulatory environment that will increase financial risk that ensures financial health of the organization. In keep intact with these risks the health care system must assume responsibilities that will encourage prompt action that will eliminate any wrong doing on behalf of the organization. The health care organization must maintain good judgment standards and portray a unique health care system that provides quality and efficient health care to his or her patients. Almost everyone involved with the delivery of health care is suppose to be trustworthy and is devoted to his or her patient's welfare. However, some are not, and health care fraud laws help control cheating in the health care system. The federal government has implemented laws to dissuade health care physicians and other provider from implementing fraudulent Medicare and Medicaid claims.

Provide four (4) examples of Qui Tam cases that exist in a variety of health care organizations.

Health care Qui Tam fraud occurs when health care providers or others falsely report charges to payers. In the instant that a provider may bill for services that were not performed, overcharge for services, or fail to provide complete services to recipients. In federal law, this means that misuses of money that the government has allocated, such as Medicare funds, is illegal because taxpayer's dollars are misspent. For example--billing for services that were not medically necessary, not rendered, upcoding, and anti-kickback are illegal practice resulting in improper payment for the health care organization.

LACK OF MEDICAL NECESSITY:

It is illegal to bill Medicare for services or treatment rendered to patients that are not medically necessary or not need. Under the False Claim Act this type of service is a violation of the intentionally billing for services that were not related to the patient conditions.

Case: An ophthalmologist agreed to pay millions of dollar for unnecessary medical services render to patients. The ophthalmologist medical chart did not give explanation of the scope of service that was submitted for medical billing to Medicare. In additionally, the ophthalmologist billed the same service more than once to Medicare for direct billing (Phillips & Cohen, (2012).

SERVICES NOT RENDERED TO PATIENTS:

Health care providers bill Medicare or Medicaid for services that he or she never performed on patients. Medical supplies and medical equipment were billed but were never delivered. There have been lab or medical tests billed but were never performed or even occurred. In some instant Medicare patients were treated for illness or condition when in fact the provider never treat or render any type of services to the patients.

Case: An orthopedic surgeon billed for services performed while he was reported to be out of the country playing golf at a medical convention. He also billed for services performed by unlicensed therapy personnel (Oswald, (2011).

Case: A nursing home chain agreed to pay millions of dollars for a variety of falsifications, including falsification of nursing logs to make it appear that the nurses