Healthcare Qui Tam - Term Paper Example

? Healthcare Qui Tam Healthcare Qui Tam Question Research s and hospitals collect billions of dollars per annum in state and federal grants for research, as well as other specialized endeavors, in the health care sector. Principally, these grants have firm parameters within which the funds can be spent, and just for the objectives set forth and permitted in the grant (Williams, 2009). Nevertheless, institutions at times shift overheads between grant programs to obscure cost overruns and mischaracterize the objectives for which they are using the funds. Such acts are what brought about the formation of the False Claims Act lawsuit – Healthcare Qui Tam. This act affects healthcare centers in numerous ways. First and foremost, it reduces fraud within the healthcare setting (Williams, 2009). This is because medical practitioners who are found to be using hospital funds for the wrong purpose are heavily fined. Examples of such fines will be explained in part two of this paper. Healthcare Qui Tam is an extremely powerful act, both in its insertion of the private citizen and their advocate. It affords private citizens as whistleblowers litigant, incorporating its checks and balances against government working (Williams, 2009). Any healthcare center, which acts against this law, will be subjected to stern actions. Therefore, this law restricts hospitals or any other medical center to act in line with the law and avoid any fraudulent act. Question 2 In Virginia, many hospitals were billing for outpatient procedures with codes kept for physician’s office visits rather than an outpatient procedure performed at the health center. Medicare pays a high rate for physician’s office appointments to mirror the cost of their operating cost (Warren & Benson Group, 2009). Hospitals obtain a separate facilities fee to settle the overhead cost. Therefore, the correct repayment rates for hospital outpatient services are lesser. The hospitals agreed to a payment of $3 million. A Pennsylvania hospital settled on paying a $2.7 million defrayal due to its upcoding fraud. The center was submitting claims for a multifaceted form of pneumonia when the accurate diagnosis showed a simpler form, which is compensated at a lower rate. The hospital decided to pay $500,000 for other upcodings with counterfeit claims for septicemia (Warren & Benson Group, 2009). A Florida hospital decided to pay $2,531,000 for issuing false claims for laser procedures executed as part of post cataract elimination surgery by demonstrating that the procedures were executed after the 39-day post-operative phase. It is also issued claims for actions, which were either never upcoded or rendered. Finally, they issued claims for two management services and evaluations per patient visit. Finally, a Hawaii doctor agreed to recompense a $2.1 million settlement for issuing false claims to Medicaid. The doctor operated a pharmacy in his hospital. The doctor billed Medicaid for providing expensive drugs when the clinic issued cheaper generic substitutes (Warren & Benson Group, 2009). Question 3 The following procedure could be used to admit a patient to a hospital, which upholds the law about the required number of Medicare and Medicaid referrals. Permission letter always should be issued before the admission of the person in the hospital (McCarty, 2008). The patient should be given Pre-requisite permission for a medical procedure and not for general consultations. The beneficiary will be urged to furnish a photocopy of a valid CGHS card, a request letter from CGHS, or a photocopy of the specialist’s professional advice. After that, then the patient will be offered an admission memo. In case of a therapeutic emergency, the hospital accepted under CGHS, shall not refuse or deny admission or demand early deposit from the concerned patient. Nevertheless, the hospital accepted under CGHS, shall offer credit facilities to the respective patient on issuing of a valid CGHS card (McCarty, 2008). Rooted in the virtues of the case study on an individual foundation, the Chief Medical Officer responsible of the concerned hospital, to which the CGHS patient is attached, will grant a Permission Letter concerning admission to an acknowledged hospital. This decision is based upon the approval made by the health specialists from CGHS. Question 4 A corporate integrity program, which will mitigate cases of fraud, should have the following elements. Written Procedures and Policies Designation of a Compliance Committee and a Compliance Officer Conducting Effective Education and Training Developing Successful Lines of Communication Enforcing Regulations Through Well-Established Disciplinary Procedure Auditing and Monitoring Responding to Notice Offenses and Developing a Corrective Action Plan Written policies and procedures should include standards of conduct, as well as risk areas. These factors will assist a health center to promote integrity and avoid any noncompliance matter (Alegent Creighton Health, 2011). Conducting successful education and training means that health institutions will set programs for educating their health practitioners in order to recognize the significant matters that concern the Qui Tam. Auditing and monitoring, on the other hand, means that health centers frequently should evaluate their activities to check whether they have committed any fraud case. Finally, the health center should always respond to any case, which arises due to Qui Tam breach (Alegent Creighton Health, 2011). This will reduce any matter, which might put the health center into trouble. Question 5 The following proposals are offered to guide doctors through a checkup of their data privacy along with security programs. Conduct an ongoing and initial internal audit Develop a privacy policy Be prepared for the inevitable Give your patients control of their information Conduct due-diligence when sharing data Invest in security Before an institution can offer its patients with helpful information regarding its privacy practices and policies, it should first comprehend what they are (Klosek, 2012). Once a healthcare center has clarified its organization’s plans and policies for collecting and using patient information, they should develop and write formal policies externally and internally. It is vital to think ahead and expect the unexpected, including the prospective that the center might face a government subpoena wanting patient information. Organizations restricted to HIPAA have authorized obligations to get consent before processing activities, incorporating most third-party revelations of information. When hospitals share patient information with third parties, they rely on the third party to play their part to allow, and keep their promises to their patients for not disclosing any information (Klosek, 2012). A health institution cannot protect the confidentiality of information if the security of the data is not confined. It is essential for healthcare institutions to incorporate information systems, which will successfully secure the information of their patients. References Alegent Creighton Health. (2011). Corporate integrity program. Retrieved from Klosek, J. (2012). 7 tips to help you protect patient privacy. Retrieved from McCarty, C. (2008). Procedures for deriving specialist services referrals. Retrieved from Warren & Benson Group. (2009). Specializing in Medicare fraud qui tam cases. Retrieved from Williams, B. (2009). Taking a closer look to the qui tam act. The American Journal of Hospital Ethics, 4(8), 6-9. Read More