Articles or Case Law Search
Tiffany Carmouche, Kiara Ingram, Heidi Jansen, & Heather Mack
HCS/430
May 15, 2017
Kristen Hauck
Introduction In the health care system there are many laws and regulations that are put into place to protect the patients that use the health care system as well as the facilities and insurance companies. Unfortunately in some cases physicians, facilities and employees break these laws and cause a critical problem in the system. In the case of Park Ridge Hospital and Adventist Health Systems, Park Ridge Hospital was found guilty of insurance fraud and over charging patients. These fraudulent charges and procedures not only cost the patients money but also have a huge impact on health care all together.
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One example of many health insurance fraud cases involves a $115 million whistleblower settlement involving Park Ridge Hospital and Adventist Health System. The lawsuit arose when three longtime employees of Park Ridge hospital had creditable insider knowledge about the hospital paying kickbacks to physicians’ who were intentionally referring their patients to the hospital for illegal monetary incentives. The civil suit also alleged that the health system was overbilling patients for medical services. One example of the overbilling is when Park Ridge Hospital devised a scheme with partnering physicians to perform outpatient procedures inside the hospital for higher reimbursement when in fact the procedure could have be done in an office setting at a lower cost. The act of health care fraud not only financially hurts the victims but it also compromises the quality of the patients care and puts patients’ health at risk. Adventist Health System agreed to settle the lawsuit with the United States government for $115 million dollars which includes the whistleblower’s reward, which will roughly amount to a little over $118 million after legal fees are calculated (Moss, …show more content…
They settled on a $115 million settlement on these charges. Violating these laws has a domino effect on the health care system as a whole. From over charging patients more money than they needed to pay to filling insurance charges that were unnecessary. These laws that were broken not only changed the way they conducted their business, but was an eye opener for the community overall on how insurance fraud can effect them personally or in the long run country
Acting US Attorney Stephen Muldrow said in a statement, "Medicare Advantage plans play an increasingly important role in our nation's health care market" and "This settlement underscores our Office's commitment to civil health care fraud enforcement."
A hospital employee violated several policies mandated in the Health Insurance Portability and Accountability Act. She failed to observe the minimum necessary requirement, did not follow the confidential communications requirements, and disclosed the patient’s treatment plan and medical condition. It also appeared that the hospital’s standard staff training procedures was not sufficiently evaluated.
In the news recent was the Miami physician pleads guilty for role in $20 Million health care fraud scheme (Justice. Gov). The FBI and HHS-OIG investigated the case, which was brought as part of the Medicare Fraud Strike Force, under the supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office of the Southern District of Florida (Justice.
As aforementioned, the Sarbanes Oxley Act’s requirements reduced fraud and increased corporate governance across both for-profit and not-for-profit organizations. That said, the SOX act has, in my opinion, been absolutely effective in regulating ethical behavior among for-profit as well as not-for-profit health organizations. The establishment of this law has contributed greatly to the investigations of fraud among health care organizations. According to attorneys at Post and Schell, several federal, criminal investigations have been started after the law’s enactment, making it clear that healthcare organizations were within the same scope of corporate governance and would not be immune from the same criminal prosecution. In 2003, United Memorial Hospital in Michigan—a not-for-profit healthcare organization—signed a guilty plea in federal court admitting to fraud for over use of pain management surgical procedures after the death of a patient. Even though sentencing has been deferred, this admittance of and plea agreement contained many of the corporate “not-tos” from the board down. The system of reporting for the hospital, its internal audit investigation, conflict of interest disclosures and response to complaints were all held as objects of interrogation (Levine & Short, 2004).
The HealthSouth Fraud ACCT 480: Forensic Accounting Emily Bauer 2/7/2016 At the time when the HealthSouth fraud was discovered in 2003, HealthSouth was the largest owner and operator of inpatient rehabilitative hospitals as well as a provider of surgical and diagnostic services. Employing more than 60,000 people at their 2,000 locations, this billion dollar company had locations in all 50 states as well as operations in the U.K., Canada, Australia, Puerto Rico and Saudi Arabia. In 2003, they were the third largest healthcare company based on revenue.
It is easy to see how fraudulent medical billing is having a major impact on the Unites States and the citizens of this country who rely on it on a daily basis. We often hear through the various new sources in this country, on the internet or out of the mouths of politicians and experts in the healthcare field about the failing healthcare system in this country. We often hear many different opinions on what needs to be done to fix our healthcare problem within this country and fix what looks to be a very broken system at this point. No matter what the solution to our poor healthcare system is one thing that is very clear is that healthcare fraud and abuse is playing a major role in the depletion of money in this country and the rise in healthcare costs for the citizens of this country.
From a personal standpoint I believe that the excessiveness of litigation is hurting the field of healthcare due to the affects in many different areas. It reduces access that patients need. Due to the misuse and disloyal antics of people making false accusations to self gain we will continue to see a rise in healthcare. I do not feel that all accusations are false, but I do believe that litigation has become successful due to dishonesty. In order for there to be financial distress for us all as a country we must flow diligently with each other. From a malpractice standpoint they need to ensure that their patients are taken care of to the best of their ability and that they are taking the precautions needed to ensure no
From the 2 million journal entries under $5,000 recorded to source documents fabricated, HealthSouth went to great lengths to commit and conceal its fraud. In addition, employees were closely monitored to ensure that they were not arousing suspicion to HealthSouth’s fraud. The leading force of HealthSouth’s culture was the
The health law field presently exists at the precipice of enormous change. Care providers must manage the legal implications that come with networked electronic health records (EHRs) and payment based on patient outcomes. Problems also arise due to patients travelling solely for specialized treatment and growing pains attributable to newly merged and acquired healthcare organizations. These factors and more contribute to increasing litigation involving fraud, insurance disbursements
Patients come to healthcare systems expecting to receive the high quality care necessary to treat various illnesses they present with. Unfortunately, events do occur which can lead to criminal and/or civil charges. Criminal law requires the punishment of jail or prison time whereas civil law results in monetary compensation and is the most common form of law healthcare workers may encounter (Allen, 2013). Certain cases can be violations of criminal and civil laws such as in the case brought against a nurse that worked at Vermillion County Hospital in Clinton Indiana.
The FBI estimates that annually the financial burdens related to healthcare fraud total in the tens of billions of dollars for the US economy. In 2014 alone, healthcare fraud totals outpaced inflation related costs and accounted for more than $3 trillion (Rooting out Health Care Fraud is Central to the Well-Being of Both our Citizens and the Overall Economy, n.d.). To expand upon the various laws which were cited in the article published by the HHS, these laws individually aid greatly in the deterrence of healthcare fraud large in part to their intended purposes. For example, the False Claims Act (FCA) protects the government from being knowingly overcharged for a good or service, the Anti-Kickback Statute (AKS) makes it unlawful to knowingly
There are a number of cases that have been tried for fraud and abuse here are a few examples: There was a $6.35 million fraud settlement at Robert Wood Johnson University Hospital Hamilton, NJ. In Sacramento the was a five physicians team that a grand jury indicted in June for running an alleged Medicare fraud scheme worth $5 million. And a Michigan Neurologist was accused of falsely diagnosed seven patients to increase test volumes. All seven were healthy patients so there was a lawsuit but the hospital insisted that his compensation was not due to
Administrators of a healthcare facility “must also take into consideration that FCA violations can create barriers to their participation in government programs, such as Medicare and Medicaid. Exclusion from these programs could be devastating to organizations that generate significant revenues from those sources.” (Mattie, A., & Rosalyn Ben-Chitrit. (2009).). The issues of the False Claims Act have been brought to the public’s attentions under “qui tam actions”. These actions are a “public partnership with private individuals and congress, who closely observe or were involved in fraud. As part of the partnership agreement, the private individuals bringing suit on behalf of the government were entitled to a portion of the monetary damages recovered as a “bounty.” (Estrada) Current stakeholders such as CMS, private funding, public, and other government agencies will not take claims being filed illegally lightly. They are the ones who are loosing money in the process. The False Claims Act is being addressed to the upmost seriousness by the United States government towards the healthcare facilities.
Health care is a tricky business that has strict guidelines that the healthcare industry must adhere. Tort laws are in places as a guide for developing health care project management as it provides the expectation of the provider and the organizations and clearly indicates the potential consequences if there is any wrongdoing. The chief factor in which tort laws offers a resolution is it lays a foundation for administrators to comprehend the level of expectation for quality medical care. Although the health care industry is involved, the laws allow for clear and precise strategies that will aid the industry in making conscious decisions when delivering care and reduce the level of preventable medical errors.
Medical fraud and abuse is a huge contributing factor in the rise of healthcare costs in the United States. Although there are many definitions of fraud and abuse, according to Cigna and HIPPA, medical fraud is when there is false representation of a substance, device or a therapeutic system as a way of being beneficial in treating a medical condition, diagnosing a disease, or maintaining a state of health. Medical Abuse is defined ‘as any action that intentionally harms or injures another person’. It also involves actions that are inconsistent with accepted medical, business or fiscal practices. Abuse can directly or indirectly result in unnecessary costs to medical programs through improper payments. Insurance fraud occurs when companies and its agents intentionally misrepresent facts for financial gain.