Effects of the Qui Tam Act on Health Care Organizations

Committing medical coding fraud or abuse is extremely detrimental to the healthcare industry. They both lead to higher healthcare costs and an increase in the cost needed for medical coverage. In addition, the increasing discovers of these acts are putting a very negative light on healthcare workers, including those who are not committing either act. With the medical world being so complex we often instill and great amount of trust in the persons taking care of medical billing and coding, this trust also makes committing fraud and abuse easier for dishonest people to take advantage of.

One of the most critical factors which contribute to the number of preventable cases of healthcare harm is the culture of silence surrounding these cases. The fear of medical providers to report incidences is related to the possibility of punishment and liability due to a medical error (Discovery, 2010). The criminalization of some acts of medical error has resulted in job dismissal, criminal charges and jail time for some healthcare workers. This is despite the fact that the system they are working in helped to create the situation which led to the error in the first place. Human error, due to fatigue and system errors can result in deadly consequences, but by criminalizing the error it effectively shuts down the ability to correct the root problem. Healthcare workers, working at all levels within the medical system, can provide valuable input on how to improve the processes and prevent harm from occurring (Discovery, 2010).

Organizational misconduct is the chief cause behind corporate accounting scandals. The trusted executives of the corporation participation in actions during a scandal are corrupt and illegal. In the United States, the Securities and Exchange Commission (SEC) is typically the government agency that investigates such scandals. One of the most notorious corporate accounting scandals in the United States is the HealthSouth Corporation scandal of 2003. HealthSouth Corporation is one of the United States largest health care providers with locations nationwide. A deeper inspection of the HealthSouth scandal is needed to understand how it transpired by assessing how it was executed, the accounting issues and root of the issue, how it was exposed, the results to the company and its officers, and warranted ramifications as an outcome of the scandal.

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.

Although, the fact of this case is, the project is being funded by public’s money and my company is misusing the fund. I have taken every step to follow organizational steps to solve this issue within the company because I never wanted to be involved in an organizational disobedience by going against an organizational policy. However, here the quality of the project is in question because of the wrong submissions of one subcontractor, so I argue that problem of the project must be solved. To resolve the issue, I decided to take a further action by whistleblowing to the public by taking information that I have

Furthermore, a government can usually make some request for an extension. In this case, the government can take over win or settle relator to receive 15% and 25% from the government award. It will depend on his involvement case. Also, the government cannot be intervening to the relator to choose whether it may continue by his own. If Dr. Prost wins he will recover some 30% of the government awards up to 30%. His court will be reducing some relator awards that are involved from the improper activities from the event. I will give some example if an employee will depend on the contractor to discovered his boss it was defrauding the government. The employee can be a file from the False Claims Act that can suit from the qui tam against his employee. By filling the suit the Department of Justice will make some consultation with the Local District Attorney. It can choose the intervene. The employee would be entitled from the percentage 15% and 25% of the governments awards. Throughout this topic, some False Claim act can be relator that should be entitled to the whistleblower

Healthcare finances does not come without legal and regulatory issues. Issues in healthcare finances are false claims and whistleblower suits. The False Claims Act is a federal law that cover fraud in any federal funded program such as Medicare and Medicaid. This act covers knowing or conspiring to falsify any claim for payment by the federal government. In 2010 alone the government recovered over $7 billion in false claims, healthcare and pharmaceuticals made up 75% of total payment. And since then more than $130 million of claims has been settled.

(Nesbitt, 2017) These laws help with healthcare prevention and fraud they are called “The Three-Headed Monster of Healthcare.” These rigid laws of enforcement scare many healthcare providers. (Nesbitt, 2017)What makes it worse, the FCA has a qui tam provision that allows private individuals to file enforcement actions with the government's help. (Nesbitt, 2017) These people are considered whistleblowers and they have up to 30 percent success rate. (Nesbitt, 2017)They became established in part due to the Patient Protection and Affordable care Act (ACA). (Nesbitt, 2017)

Health insurance fraud is what drives up health insurance premium costs, wastes taxpayer’s money, but can also endanger beneficiaries or leave them uninsurable. In 2015, Medicare Strike Force reported over $700 million in false billing by doctors, nurses, other licenses medical professionals, laboratories, and individuals (FBI.gov). This is a staggering figure that is only getting worse. In this fictitious federal case I will be describing the criminal offender, the crime that was committed, the charge handed down by law enforcement, and the judicial process from the beginning of the criminal case to the sentencing of Dr. Richard Heartman, an internal medicine physician.

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

The typically overlooked crime of healthcare fraud has resulted in a significant monetary loss on the part of the American public paying into government run medical programs, as well as private insurance company programs. Historically, we have seen that in any instance where money is involved people have found ways to or at least have attempted to obtain it illegally. Some do it through overt acts of violence such as a robbery. Others choose more covert ways of illegally obtaining money. This is usually conducted through fraudulent activities. This is the nature of white-collar crime. There is no force or violence involved but it is still illegal. (SSA) Obviously, when such a large amount of money is involved there is

This thesis is written to provide a historical and policy evaluative perspective on the topic of the False Claims Act and it’s Qui Tam provisions. The False Claims Act is a fairly old Act, dating back to 1863. The Act was first enacted to fight procurement fraud but in recent years the focus has turned to health care fraud. This thesis will seek to determine whether or not the False Claims Act and it’s Qui Tam provisions are an effective tool in fighting fraud, in particular health care fraud. The focus of this thesis will be to evaluate the False Claims Act (FCA) and in particular its Qui Tam provisions. A closer look will be taken at the emergence of a very lucrative type of fraud in the United States. This type of fraud has only been on

Under the qui tam and provisions of the False Claims Act, The lawsuits were filed by Dr. Michael Mayes and other three whistleblowers. Also, two of the lawsuits separately were against the previous CEO Phillipe Goix of Berkeley as responsible for the scheme.

Bouville (2008) describes whistleblowing as an act for an employee of revealing what he believes to be unethical or described as an illegal behaviour to a higher management (internal whistleblowing) or to an external authority or the public (external whistleblowing). Whistle-blowers are often seen as traitors to an organisation as they are considered to have violated the loyalty terms of that organisation while some are described as heroes that defend the values and ethics of humanity rather than loyalty to their company. In the medical community, it is the duty of a practitioner aware of patient care being threatened to make it known to those in charge and for those in charge to address the issues and act on it. The General Medical

A good definition of Fraud, Waste and Abuse (FWA) can be found in U.S. Air Force Regulations and can be applied to any government (or private) organization, it states: