Chief Nursing Officer response to fraudulent qui tam cases in obstetric healthcare

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 fraud plus $5,500-$11,000 per fraudulent claim" (Mattie & Ben-Chitrit, 2009). 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. But, despite the small scale overall it can add up to a lot of money. Healthcare agencies need to make sure that they are staying current with Medicare and Medicaid rules regarding admissions criteria.

The plan would have to make sure that referrals of patients were legitimate and not subject to any doctor fraud for kickbacks (ASLHA, 2010). The issue with self-referral is that doctors were sending patients to their own clinics for aftercare such as physical therapy (Hanford, 2001). Kickback laws refer to anyone who "knowingly and willfully offers, pays, solicits, or receives remuneration in order to induce business reimbursed under the Medicare or Medicaid programs" (ASLHA, 2010). The admissions policy would have to include language that specifically guarded against such practices and set penalties if they did occur.

The policy would also have to include specific language that is required by the government. Since Medicare and Medicaid account for approximately one-third of all payments for patient admissions (Hanford, 2001), it is important to follow their guidelines. These also include regulations designed to stop payment fraud.

Corporate Integrity Program

Installing a corporate integrity plan that is comprehensive and takes into account different laws an procedures can be difficult, but becomes easier if there is a designated body assigned to the task (Yuspeh, et al. 1999). A good primer for a corporate integrity plan comes from Alegent-Creighton Health (2012) which lays out the plan as such:

Written policies and procedures which include standards of conduct and potential risk areas

Designation of a Compliance Officer and a Compliance Committee

Conducting effective training and education

Developing effective lines of communication

Enforcing standards through well-established disciplinary guidelines

Auditing and monitoring, and;

Responding to detected offenses and developing corrective action plans

This plan includes all of the elements that Yuspeh, et al., (1999) and other researchers have regarded as critical to the success of such an endeavor. It covers all possible contingencies and is flexible enough to ensure future stability.