Medicare fraud and abuse refer to the claiming of the Medicare reimbursement in health care to which the person claiming is not entitled. According to Parver and Goren (2011), Medicare fraud and abuse in the United States account for about 4%-15% of the healthcare’s annual expenditure. There are several types of Medicare fraud and abuse, of which all of them are having the same goal of illegitimately collecting money from the Medicare program. Therefore, this report provides and discusses a real-world example of this issue, identifies the involved ethical principles, the legal implications including the statutes and laws involved, and the appropriate procedures and policies for preventing such fraud from happening again in future.
Real-World Experience Case Study
An example of a real-world case of this issue is seen from the Medicare fraud settlement by the Brookhaven Memorial Hospital Medical Center. This Memorial health institution agreed in paying $2.92 million together with interest for settling fraud allegations that the institution inflated health care charges for obtaining the outlier supplemental payments. As a result, the United States Justice Department intervened in this suit and made allegations that the Memorial hospital indeed defrauded Medicare ( New perspectives in healthcare, 2015) . These outlier payments were only intended for the cases whereby healthcare costs were unusually high, but as alleged by the Justice Department, Brookhaven received these payments for the health care cases that were not extraordinarily costly, and therefore, should not have merited them.
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Involved Ethical Principles
From this fraudulent case, it can be deduced that Brookhaven Memorial Hospital failed to honor the policies guiding medical ethics, which observes that health care fraud is wrong. Besides, the healthcare professional oaths, guidelines, declarations, and codes require the professionals of healthcare to be trustworthy and honest, something that Brookhaven professionals failed to honor.
Additionally, Brookhaven hospital failed to comply with Principle/Standard 7 of the ‘Code and Standards.’ This principle directs healthcare institutions as well as therapists in promoting and supporting business practices and organizational behaviors, which benefit the clients/patients and the general society. Moreover, this principle observes that it is vital for healthcare professionals in understanding the negative impact of losses to the U.S. health care system as a result of abuse, waste, and fraud, and hence take the responsibility of understanding this effect in addition to curbing fraud (Golinkin, 2013). It, therefore, implies that instead of preventing fraud, Brookhaven significantly promoted the act of fraud, which was ethically wrong.
Furthermore, Brookhaven Memorial hospital also failed to comply with the Principle/Standard 5 of medical health. This principle articulates the related fraud and abuse ethical responsibility of healthcare professionals besides mandating that healthcare professionals fulfill their professional, legal, as well as ethical obligations. It further states that healthcare professionals must comply with the applicable state, local, and the federal laws and regulations (Griffith & Shaw, 2014). Therefore, by violating the Medicare law by engaging in fraud and abuse practices, Brookhaven violated the ‘Code and Standards’ of the medical ethical conduct.
Also, Brookhaven hospital failed to comply with Principle/Standard 8 of the medical ethics. It addresses the responsibility of healthcare professionals to take part in efforts of meeting the health needs of individuals globally, nationally, and locally, with 8C mainly directing healthcare professionals in being responsible stewards for the resources of health care (Parver & Goren, 2011). As the principle obligates, Brookhaven failed to avoid fraud and abuse.
Legal Implications
This suit was formerly filed in 2005 by Tony Kite, a whistleblower in the United States District Court for the New Jersey District. The U.S. Department of Justice in November 2009 intervened in this suit. Moreover, Tony Kite brought this suit to the court under the False Claims Act provisions. The provisions of this Act authorize private citizens with fraud knowledge against the U.S. government in filing a lawsuit on behalf of the U.S. in addition to sharing of any recovery ( New perspectives in healthcare, 2015) . Therefore, it was under the civil settlement of this Act that Tony Kite was reimbursed about $613,000 together with interest, out of the total proceeds from the settlement.
Moreover, the United States Attorney for the District of New Jersey, Paul Fishman stated that the Department of Justice is much determined in rooting out any misconduct that threatens in undermining the federal health care programs integrity. Moreover, the settlement of this suit was successful following a coordinated effort by the U.S. Attorney for the District of New Jersey; Department of Justice Civil Division Commercial Litigation Branch; Health and Human Services Department, Affirmative Civil Enforcement Unit; Office of Inspector General; the Federal Bureau of Investigation, as well as the Centers for Medicaid and Medicare services. Importantly, the settlement of this suit was part of the emphasis taken by the U.S. government to combat fraud and abuse in health care (Golinkin, 2013).
Policies and Procedures
To prevent health care institutions including Brookhaven from taking part in healthcare abuse and fraud activities, providers are expected in understanding fundamental health care fraud laws, compliance program implementation, and improving medical billing in addition to business operations processes (Griffith & Shaw, 2014). There are specific three essential laws established by policymakers for regulating both the healthcare abuse and fraud cases as well as creating a statute for criminal healthcare fraud.
The Federal False Claims Act is a policy and procedure for imposing civil liability on any person who causes the submission of, or knowingly submits, fraudulent or false claims to the federal government. In this case, there would be no need for law officials to ask for specific intent proof for defrauding to charge people.
The Physician Self-Referral Policy prohibits the healthcare professionals from making any referrals for specific reimbursable health care services by the government healthcare programs. In fact, these referrals should not be made to those entities that healthcare professionals or their immediate family members are having an investment or ownership interest, or with which they are having an agreement for compensation, commonly known as Stark Law.
The Anti-Kickback Statute policy targets healthcare providers who willfully and knowingly solicit, receive, pay, or offer direct or indirect remuneration for rewarding or inducing referrals of items and services by the federal healthcare programs. Therefore, healthcare providers who violate the laws of healthcare fraud could be excluded from the civil monetary penalties and federal healthcare programs (Parver & Goren, 2011). Moreover, the federal judges are also provided with the mandate of sentencing these violators to prison.
Therefore, it is also vital for the federal government in implementing a compliance program for identifying and preventing healthcare abuse and fraud practices. However, such a compliance program should be strong enough to have the ability to establish a culture in a hospital, which would be responsible for promoting detection, prevention, in addition to the resolution of conduct instances that do not comply with the State and Federal law and the ethical policies of a hospital ( New perspectives in healthcare, 2015) .
References
Golinkin II, J. W. (2013). Fishing with Landmines: Healthcare Fraud and the Civil False Claims Act--Where We Are, How We Got Here, and the Case for More Trials. American Journal Of Criminal Law, 40(3), 301-326. https://www.questia.com/read/1P3- 3080244951/fishing-with-landmines-healthcare-fraud-and-the-civil
Griffith, R. A., & Shaw, P. W. (2014). FRAUD & ABUSE INVESTIGATIONS HANDBOOK FOR THE HEALTHCARE INDUSTRY. Journal Of Legal Medicine, 22(3), 441-446. doi:10.1080/01947640152596470. http://www.hcca- info.org/portals/0/PDFs/Resources/hcca-2017-resource-guide.pdf
Parver, C. P., & Goren, A. (2011). Significant Details from the 2010 Health Care Fraud and Abuse Control Program Report. Journal Of Health Care Compliance, 13(3), 9-22. http://mds.marshall.edu/cgi/viewcontent.cgi?article=1112&context=mgmt_faculty
New perspectives in healthcare (2015): Impacts of regulation, organization, reform and change in the United States health system . http://www.econ.boun.edu.tr/content/2015/summer/EC- 48B01/Lecture%20Note-11_Yilmaz2013-08-03-2015.pdf
