Dr. James Coon, Jr
HSA 515 Health Care Policy, Law, and Ethics
June 16, 2013
As the Chief Nursing Officer of the state’s largest Obstetric Health Care Center, this author is responsible for complaints regarding fraudulent behavior in the center. The purpose of this report is to (1) evaluate how the Healthcare Qui tam affects health care organizations, (2) provide four examples of Qui Tam cases that exist in a variety of health care organizations, (3) devise a procedure for admission into a health care facility that upholds the law about the required number of Medicare and Medicaid referrals, (4) recommend a corporate integrity program that will …show more content…
Attorneys in the national qui tam whistleblower practice of Pietragallo Gordon Alfano Bosick & Raspanti successfully represented the lead relator in one of the largest cases of “unbundling” in the history of false claims litigation, United States ex rel. Merena v. Smithkline Beecham Clinical Labs, which resulted in a recovery of $328 million for federal taxpayers.
False Certification: When physicians, hospitals and other health care providers submit bills to government health care programs they are required to include a number of important certifications, including that the services were medically necessary, were actually performed, and were performed in accordance with all applicable rules and regulations. Additionally, health care companies such as pharmaceutical companies and pharmacy benefits managers that provide products or services to government health care programs are required to certify that they are satisfying all obligations under their contracts with the government. One common type of fraud has been to falsify these certifications in order to get a health care claim paid or to obtain additional business” (Raspanti, n.d.).
Stanton (2001) acknowledges that in a healthcare facility, with Medicare, each false claim is considered an individual billing whether for a specific medical item or service. Penalties can rise quickly with suspension or delay payment of future claims for a facility if it has been accused of submitting false