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…show more content… §1328-7b(b), the Federal False Claims Act, as well as various other federal and state laws and regulations.
Ghost Patients: The submission of a claim for health care services, treatments, diagnostic tests, medical devices or pharmaceuticals provided to a patient who either does not exist or who never received the service or item billed for in the claim.
Up-Coding Services: Billing of government and private insurance programs is done using a complex series of numerical codes that identify the specific procedure or service being performed. These code sets can include: the American Medical Association’s Current Procedural Terminology (“CPT”) codes; Evaluation and Management (“E&M”) codes; Healthcare Common Procedure Coding System (“HCPCS”) codes; and International Classification of Disease (“ICD-9”) codes. Government health care programs assign a dollar amount it will pay for each procedure code. Up coding occurs when a health care provider submits of a claim for health care services, treatments, diagnostic tests or items that represent a more serious and more expensive procedure than that which actually was performed. Up coding can be a violation of the Federal False Claims Act.
Bundling and Unbundling: In many cases, government health care programs have special reimbursement rates for groups of procedures that are typically performed together, such as laboratory tests. One common type of fraud has been to