Health Care Policy, Law and Ethic Essay

As a Chief Nursing Officer, Im responsible for one of the conjures largest Obstetric wellness help Centers. I just received word of some double-dealing behaviors in the kernel. To mitigate this type of behaviors I must evaluate how the health make out Qui tam affects health financial aid organizations, allow four examples of Qui Tam shields that endure in a variety of health consider organizations, Devise a procedure for admission into a health divvy up facility that upholds the fairness to the highest degree the unavoidable number of Medicare and Medicaid referrals, Recommend a corporate impartiality program that get out mitigate incidents of fraud and assess how the recommendation will imp action stretch forths of reproduction and birth, and Devise a plan to protect longanimous nurture that complies with entirely demand justnesss. After completing my evaluation on Qui Tam I will be equal to(p) to provide a proper protocol to handle or prevent future issue and grow awareness on how fraudulent behavior affects the health care center.Qui Tam is Latin for he who selects a case on behalf of our entitle King, as well as for himself. Qui Tam allows a private citizen (relator, whistleblower) to bring a integritysuit on behalf of the g all overnment, as well as himself, against a suspect who may has knowingly committed fraud or woeful act in which the government was victimized (Showalter, 2012). The private citizen need not have been personally harmed by the suspects charter (Department of the national Office of tester General, 2010). The government can choose to take over the prosecution, but if the government declines the private citizen can snuff it alone. How wellnesscare Qui Tam affects health care organizations.wellnesscare is a multi- circuit cardion dollar industry and has attracted those who wish to defraud health insurance companies and the government (Showalter, 2012). Based on the healthcare industry monetary encourage it has become the fertile soil for vacuous collar crimes that end in criminal convictions and financial penalties (Showalter, 2012). The punishment for salary fraud and poke fun is regiond with the abuser and the organization. When an employee is involved in act of fraud and abuse management, officers as well as the organization is held accountable. They share in the punishment even if management, officers or the organization is aware of the abusers actions. . 1 way to minimize exposure to fraud and abuse is to have a strong corporate residence program in go down. Developing a strong complianceprograms will find an organizations bond paper to federal official and state regulations such as anomalous arrogate act, anti-kickback statues, the stricts self-referral laws and HIPAA. victimisation government regulation as the bases of an organizations compliance program will friend blessificantly in the effort to prevent fraud, abuse and waste in spite of appearance the org anization (Showalter, 2012).Healthcare Qui Tam along with state and government regulations has pushed organizations to civilise new or stronger compliance programs in the hopes to prevent fraud, promote fair play and improve billing accuracy. Not only has it push health care organization to create compliance program to protect the confederation these polity as well include process for an employee to anonymously report and undesirable hire they may see. Companies have also created their own fraud and abuse compliance departments that are responsible for educating the cater of whatsoever federal and state regulations and created extremity for and standards each depart must to abide by. This department will also be responsible for the investigation of any reported behavior. These measures are amaze in place to prevent any possible fraud and abuse acts with in the organization. employments of Qui Tam cases that exist in a variety of health care organizations. To remedy abuse associated with tinge billing, up coding, unbundling, and billing for unequal to(predicate) or surplus care the government put in place the false studys act. During January 2009 through 2012 the justice department use the false claim act to recover more than 9.5 billion dollars in health care fraud cases. Below is an example of a False Claim symbolize mooring.Example of FCANelson v. Alcon Laboratories, No. 312-cv-03738-M (N.D. Tex.) kick filed kinsfolk 14, 2012Complaint incertain July 16, 2013 interference status DeclinedClaims False claims to Medicare, Medicaid, TRICARE and the federal defense procurement programs in violation of the Civil False bend (FCA), 31 U.S.C. 3729 et seq. Name of Relator Michael Nelson and Steve Gonzales defendants Business Pharmaceutical manufacturerRelators relationship to suspect designer employeeRelators Counsel Bell, Nunnally & Martin, LLPSummary of case Alcon Laboratories assert(a)ly failed to adhere to FDA regulations in manufacturing , box and delivering nonprescription and prescription eye care products sold to the U.S. government down the stairs Medicare, Medicaid, TRICARE, and other insurance programs held by a variety of military and federal employees and their dependents. Alcon even provide the eye care product to the U.S. Department of defenceCurrent status The U.S. declined to interfere in the case relator may proceed on their ownReason to Watch This case was viewed homogeneous to unify States ex rel. Eckard v. GlaxoSmithKline and SB Pharmco Puerto Rico, which was settled in 2010. This case involved both(prenominal) civil and criminal allegation, but the focus was on failing to obey with the FDAs regulations regarding manufacturing puts and product quality. This case resulted in a guilty from the defendant, a civil answer of $600 billion, and a criminal fine of $150 million.Anti-Kickback Statue is a criminal statute that prohibits the exchange or offer of an exchange, of any value or form, in t he efforts to induce or reward the referral of federal health care program traffic. This statue was creates to establish penalties for several(prenominal) and entities on both sides of the proscribe exchange. If convicted the violator can be fined up to 25,000 and sentenced up to quintet years. In lieu of the fine and the jail time the violator(s) can be excluded from combat-ready in federal health care programs. Listed below is an example of an anti-kickback statue case.Example of AKSUnited States ex rel. Nevyas v. anyergan, Inc., No. 209cv432 (E.D. Pa).Complaint Filed January 30, 2009 ( Second Amendment Complaint Filed September 27, 2010) Complaint Unsealed December 16, 2013Intervention Status unreadable from docket Claims The relators assert that the defendant caused the submission of claims for payment for prescription drugs bring forth by illegal kickbacks in violation of the FCA, as well as analogous false claims statutes of 19 states and the District of ColumbiaRelator s Names Herbert J. Nevyas.Anita Nevyas-Wallace, M.D. Defendants Business The defendant is an international biopharmaceutical company Relators Counsel Pietragallo, Gordon, Alfano,Bosick& Raspanti LLP (Philadelphia, Pa)Relators Relationship to Defendant The relators are third party atomic number 101s who claim they were offered the alleged inducements by the defendant. Current Status OngoingSummary of shield The relators allege the defendant violated the Anti-Kickback Statues buy offering ophthalmologists and optometrists to prescribe the defendants unshared chronic dry-eye prescription drug Retasis. According to the defendant Allergan offer unloose consulting run, free acesss to a restricted weathervanesite, invitation to and payment of expenses related to advisory room meetings and offers to fund independent look.Reason to Watch The defendant entered into a five year bodied Integrity Agreement with the Department of Health and human beings Services, Office of inspector Ge neral in connection with a settlement of an unrelated criminal investigation and Qui Tam action. Some of the conducted listed in this case may have occurred while the defendant CIA was in place. besides position out possible compliance issues for pharmaceutical companies seeking to grow their business through relationship with docs (Abhar, Grammel, McGinty, & Willis, 2014) Example of billing for un demand service and ghost billing United States ex rel. Fife v. Lymphedema and Wound Institute, Inc., Civ. No. 0411-CV-271 (S.D. Tex.).Complaint Filed September 22, 2011Complaint Unsealed November 25, 2013Intervention Status The United States intervened.Claims Defendants allegedly submitted false claims for treatment of lymphedema Name of Relator Dr. Caroline FifeDefendants Businesses The individual defendants are the executives and owners of the defendant company and its affiliates, whose employees provide physical therapy and treatment for lymphatic disease. The individual defendants a lso managed and operated a net run of sleep-study clinics.Relators Relationship to Defendants Relator is a competing physician and professor at the University of Texas who often treated tolerant roles who hadstopped receiving treatments from defendants facilities. Relators Counsel Ahmad, Zavitsanos, Anaipakos, Alavi & Mensing P.C. (Houston, TX)Summary of Case The Relator alleged that the defendant provider used unqualified massage therapist to provide services to their lymphedema perseverings. Also accord to the relator the defendant bill for unnecessary services as well as services and supplies that were never rendered. Lastly, the relator alleged the defendant used similar scheme to inflate billing services that were rendered at their sleep clinic.Current Status The parties settled the claims related to lymphedema treatments for $4.3 million. Additionally, the defendant companys founder and chief executive officer voluntarily submitted to a 10-year censure from federal health benefit programs and the defendant company entered into a five-year Corporate Integrity Agreement (CIA) as of June 25, 2013 (Abhar, Grammel, McGinty, & Willis, 2014).Reasons to Watch Although the amount of the settlement $4.3 million is relatively modest when compared with the $165 million in fraudulent Medicare billings alleged in the complaint, the voluntary exclusion of the defendant companys CEO from companionship in federal health care programs is severe, as an excluded individual will likely find it difficult to continue working in the health care industry (Abhar, Grammel, McGinty, & Willis, 2014).Example of up-codingUnited States ex rel. Oughatiyan v. IPC The Hospitalist conjunction Inc., Civ. No. 09-C-5418 (N.D. Ill.). Complaint Filed September 1, 2009Complaint Unsealed December 5, 2013Intervention Status The United States intervened, but Illinois and the other 12 plaintiff states declined to interveneClaims Defendants allegedly encouraged the filling of up-coded claims for services in in unhurried and semipermanent care facilities to federal care programsName of Relator Dr. Bijan OuhatiyanDefendants Businesses National hospitalist independent declarer company and its local subsidiaries employing physicians and other health care providers who work in more than 1,300 facilities in 28 states.1 Hospitalists are physicians who assist in directing and coordinating in uncomplaining care from admission to discharge, and only work in hospitals orlong-term care facilities (Abhar, Grammel, McGinty, & Willis, 2014).Relators Relationship to Defendants Relator is a former employee/independent contractor of dependent.Relators Counsel Goldberg Kohn Ltd. (stops, IL)Summary of Case Relator alleges that IPC The Hospitalist Company (IPC) engaged in the following schemes to cause its employed hospitalists to bill for the services they rendered at the highest reimbursement levels even though such codes were inappropriate, a practice called upcoding. The lawsuit conten ds that IPC trained its physicians to bill at the highest levels without regard to the actual complexity of the services provided. Additionally, IPC allegedly tracked the coding statistics of its hospitalists and used the results to pressure hospitalists to upcode their services to achieve productivity and profit goals. As a result of these practices, according to the relator, the medical recordation of the actual work done did not nutriment the billing records submitted by the hospitalists (Abhar, Grammel, McGinty, & Willis, 2014).Current Status OngoingReasons to Watch The defendant has another case (United States ex rel. Ziaei v. IPC The Hospitalist Company Inc., et al., Civ. No. 212-cv-01918 (D. Nev.)) with similar allegation, but was dismissed. Our Facility admission Policy, which is in accordance with Medicare and Medicaid referral guidelines. Medicare and Medicare Referral guidelines are base on the Stark law. To prevent any issues or conduct that violates the Stark law ou r facility will participate in CMS Provider Enrollment, range of mountains and Ownership System (PECOS). We will require all qualifying providers to memorialize their NPI with Medicare and Medicare by the deadline date. This system will allow us to submit claims, referral, and refresh for admittance. This program will catch any potential violations of abuse and fraud. The atomic number 101 Self -Referral law is listed below. The medico Self-Referral Law (Stark Law) (42 U.S.C. Section 1395nn) prohibits a physician from making a referral for certain designated health services to an entity in which the physician (or an immediate piece of his or her family) has an ownership/investment interest or with which he or she has a compensation arrangement, unless an exception applies.Penalties for physicians whoviolate the atomic number 101 Self-Referral Law (Stark Law) include fines as well as exclusion from participation in all Federal health care programs Corporate wholeness program that will reduce fraud and impact issues of reproduction and birth. A Corporate Integrity program is put in place to ensure the organization and the employees would not knowingly violate any laws that control the conduct of the organization operations. Staff will receive training regarding the health care centers Corporate Integrity Program and all law associated with the program.Code of ConductPromote and Preserve the organization values shelter the privateness of the Health care centers patientsProtect the confidentiality of the patient and the employee teaching o Avoid all forms of discriminationAct in accordance of all policies and proceduresComply will all law that apply to the health center operations and practices o Disclose all potential conflicts of interestNo accepting of gift, goods and servicesAdhere to all professional standard underwrite consent for service is received and documentedRefusal for services are documentPatient is informed/education of risk and requires t reat for their condition conformation of claims only for servicesThat are actually for service rendersFor services that the patient or patient represented consented to oFor services that are medical necessary for the patient condition That have appropriate documentation to support the claimAll services will be reviewed before billingAll billing ply will be trained and certifiedNo claim will be submitted that fall under the Physician Self-Referral law or Anti- Kickback statues Plan to protect patient information that complies with all necessary laws As one of the states largest Obstetric Health Care Centers in the area we have an extensive lag. The first policy is to provide excess to patient information that is in the scope of your avocation. For example the enrollment staff will not have accessto the patients lab results and the lab technician will not have access to member complete medical history. When a staff member signs on to any system that houses patient information the y will only be able to view or update information that is within the scope of the job responsibility. This way the patient private medical records are kept private. Education, training and yearly certification of Health Insurance Portability Act and the organization privacy policy will be required fall all staff members. Certification will only be provided to those that achieve at to the lowest degree an 80% on any test that is provided in training. Failure to agree will result in suspicion until certified or termination. For vivacious employees yearly certification will be done throughout web base training portal.For our new employees training and certification will be part of their new hire orientation and any future required Training will be done through our train portal. The staff can access the training portal at home. This way our staff and complete the certification at the leisure (with in the due date). Also we have the proper process in place to such as authorization and de-identifying Protection Health education when share and medical or any sensitive information with others. For example there maybe causa why a department must share the type of patient seen or the treatment provided. There should be not reason that patients name, address, or any information that may identify the patient be included in the report. We also require the patient to sign an authorization for every year, which will allow us to submit information to insurance companies for payment, medical necessity review, and appeals. We will also have the patient to sign an authorization form allowing us to speak with a particular individual, leave voice mail massages and or email the member about appointment and care. Any unauthorized disclosure of private health information the patient will be notified right away.Various federal and state laws, regulations, rules and guidelines govern the use, Disclosure and protection of health information. These include certain aliment of the H ealth Insurance Portability and Accountability Act (HIPAA), certain provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act, the Confidentiality of Medical Information Act (CMIA), and any other patient privacy-related laws, regulations, rules and guidelines will be used as the bases of our privacy policiesBibliographyDepartment of Health and Human Services. (November, 27 2013). Physician sefl Referral CMS. Retrieved 15 2014, March, from Center of Medicare & Medicaid Services Abhar, S., Grammel, S., McGinty, K., & Willis, S. (2014, February). Qui Tam Defense MintzLevin. Retrieved March 16, 2014, from MintzLevin http//www.mintz.com/newsletter/2014/Newsletters/3691-0214-NAT-HL/ Department of the intimate Office of Inspector General. (2010, October 6). False claim Act office of Inspector General. Retrieved March 15, 2014, from Department of The Interior Office of Inspector General https//www.doioig.gov/docs/falseclaimsact.pdf. Abhar, S., Grammel, S ., McGinty, K., & Willis, S. (2014, February). Qui Tam Defense MintzLevin. Retrieved March 16, 2014, from MintzLevin http//www.mintz.com/newsletter/2014/Newsletters/3691-0214-NAT-HL/ Department of the Interior Office of Inspector General. (2010, October 6). False claim Act office of Inspector General. Retrieved March 15, 2014, from Department of The Interior Office of Inspector General https//www.doioig.gov/docs/falseclaimsact.pdf. Dunphy, B. P., Kingsbury, S. P., Miner, T. A., Foster, H. S., & Willis, S. D. (2012). Health Care enforcement 2012 Trends . MintzLevin. Gumbert, J. G. (2003). Qui TamActions Under the False Claims Act. Medical Journal Houston. Levine, R. H. (2005). Internal Investigations By Healthcare Organizations Practical considerations. American Health Lawyers association. Showalter, J. S. (2012). The Law of Healthcare Adminstration (6th ed.). Chicago Health Adminstration Press. Staman, J. (2013). Health Care fraud and Buse Laws affecting Medicare and Medicaid An O verview. Congressional research Services report for Congress.