Verified Document

Healthcare Integrity Is A Major Issue For Essay

Healthcare Integrity is a major issue for healthcare organizations because there are many avenues for fraud, and for people to demonstrate a lack of ethics. The problem is that the temptation is sometimes too great and despite the fact that there are laws in place to guard against these practices unethical behavior takes place anyway. The government, which supplies a lot of the money which goes for treatments through Medicare and Medicaid, has structured certain laws to make sure that the practices of healthcare organizations are ethical, but billions of dollars in fines are still doled out every year. The big drug companies complain of arcane and hard to decipher legalese, but the fact is that although they realize the issue and the penalty they continue to subvert the law. This paper looks at qui tam statutes and cases, Medicare and Medicaid admissions criteria, installing a corporate integrity program, and patient information protection law.

Healthcare Qui Tam

The phrase "qui tam" is from the Latin and relates specifically to an action taken for the government (or king/lord) against a fraudulent individual or group. In the United States, these have been termed "whistleblower" statutes and relate to individuals noticing fraud conducted by their company and informing on them. The laws which are a part of this type of action protect the person who provides the information and allows them to do so anonymously in most cases. The statutes also allow for compensation for the individuals or group who is providing the information.

In the case of healthcare agencies or practices, this can take several forms. One study lists "Areas from patient referrals to billing and documentation have become targets for state and federal governments; investigation of healthcare fraud, false claims, and other types of noncompliance" (Mattie & Ben-Chitrit, 2009). Healthcare organizations may believe, using short-term thinking, that the fraud is not serious enough to warrant a closer investigation, but the damages the government can demand are substantial and should serve as a major warning to any organization. The statute allows that "the government may recover up to three times the amount of damages it sustained as a result of the defendant's...

This should provide healthcare managers with enough impetus to remain within the law and conduct in-house investigations when any type of fraud, etc.is suspected that could come under the Qui Tam statutes.
Qui Tam Cases

Precedent has been set in these types of cases by the number that have been taken before state and federal courts. Recently, there have been a rash of large lawsuit settlements that have benefitted both the government, the whistleblower(s) and the public. These include:

In July 2012, GlaxoSmithKline was…charged with illegally promoting nine different prescription drugs

Kidney dialysis giant DaVita Inc.…in July, 2012…agreed to pay $55 million over allegations of drug overuse, while denying wrongdoing.

In May 2012,…Abbott Laboratories Inc. plead guilty…[to] unlawful promotion of the prescription drug Depakote for uses not approved by the FDA.

In April 2012, WellCare Health Plans…settled four False Claims Act cases related to price gouging and Medicare and Medicaid overpayments.

In February 2012, Johnson & Johnson…settled a whistleblower lawsuit that charged the company with off-label marketing of antipsychotic medication Risperdal.

In November 2011, Merck & Co. (MRK),…agreed to…settle allegations the company sold painkiller Vioxx for unapproved uses and made false statements about its cardiovascular safety (Louthian, 2012).

These cases are listed because the amounts that was required to be paid when they were settled was very large. One of the above companies faced a fine of $3 billion which should demonstrate the seriousness with which the government takes such claims.

Medicare/Medicaid Admissions

Medicare and Medicaid investigate fraud in the same manner that healthcare organizations and other governmental agencies do, but these payment processors may have a larger stake in ensuring that fraud does not occur. It is also more difficult for these agencies because the fraud enacted upon them is generally in a relatively small scale and not easy to spot.…

Sources used in this document:
References

American Speech-Language-Hearing Association (ASLHA). (2010). Summary of self- referral and anti-kickback regulations. Retrieved from http://www.asha.org/practice/reimbursement/medicare/regulations_sum.htm

Hanford, J.T. (2001). Regulation of the healthcare professions. Ethics & Medicine, 17(3), 188-190.

Louthian Law Firm. (2012). Healthcare fraud qui tam whistleblower protection lawsuits.

Mattie, A. & Ben-Chitrit, R. (2009) The federal False Claims Act and qui tam actions: What every healthcare manager should know. Journal of Legal, Ethical and Regulatory Issues, 12(2), 49-65.
Cite this Document:
Copy Bibliography Citation

Related Documents

Health Care Information and the
Words: 2722 Length: 10 Document Type: Term Paper

Information technology and computers have also begun to affect, in ways that are both bad and good, family life, community life, education, freedom, human relationships, democracy, and many other issues. By looking into the broadest sense of the word it can be seen that cyber ethics should actually be understood as a branch of applied ethics, and ethics should be something that is believed in by all that provide

Health Care It Health Care Information Technology
Words: 978 Length: 3 Document Type: Essay

Health Care IT Health Care Information Technology The days of paper-based records in health care are fading. It is widely believed that the broad adoption of clinical applications such as computerized physician order entry (CPOE) can lead to major health care savings, help eliminate medical errors, and improve healthcare outcomes for patients (Lynn, 2011). Because of such benefits, the Obama administration included automated adoptions in health care as a part of its

Healthcare Information Systems Healthcare Information
Words: 1841 Length: 5 Document Type: Term Paper

2010). A complaint with many people who utilize this data is about the data entry with many particularly against the quality. ETO-HMIS boasts of fast implementation and transfer of data which puts them way ahead of any competitors. It is particularly imperative that there is the development for a culture where there is sharing of data. This leads to an increase in the checks for efficiency within healthcare. This

Healthcare Poverty Health Care Reform,
Words: 3343 Length: 12 Document Type: Research Proposal

As a result, millions of Americans remain unable to bear the heavy financial toll of medical expenses. Indeed, the problem of a lack of insurance for many is related to the problem of the cost of healthcare. So confirms the article by Consumer Reports (CR) (2008), which finds that "health-insurance premiums have grown faster than inflation or workers' earnings over the past decade, in parallel with the equally rapid

Healthcare and Management As You
Words: 1842 Length: 6 Document Type: Research Paper

Other ways to celebrate achievements would be to send thank-you cards, congratulatory notes, make phone calls, and send emails. 4. Being able to set challenging goals - people often strive to achieve what is expected of them, but if they are presented with a set of challenging goals they will work even harder to accomplish them. 5. Being able to provide the necessary tools to succeed - no team will stay

Healthcare Strategic Planning & Management
Words: 2211 Length: 8 Document Type: Term Paper

Canada. Increase benefits To gain more employees for the nursing staff, SKMC should increase their level of satisfaction by offering several incentives such as increased living expenses or better housing facilities. Moreover, they should include full medical coverage in the work contract. Regarding the foreign employees they should expand the annual leave from 42 days to at least 60 days in order for the abroad workers to be able to spend

Sign Up for Unlimited Study Help

Our semester plans gives you unlimited, unrestricted access to our entire library of resources —writing tools, guides, example essays, tutorials, class notes, and more.

Get Started Now