Governance and Fraud in Health Care Organizations: Legal and Ethical Responsibilities False Claims Act in Healthcare

 Governance and Fraud in Health Care Organizations: Legal and Ethical Responsibilities False Claims Act in Healthcare
 

False Claims Act

Name of the Law

The Federal and State False Claims Act (FCA), 31 U.S.C. §§ 3729 – 3733 is a Federal and State Law enacted in 1863 by the U.S. Congress. The FCA has been independently enacted by 31 American states including Arkansas, Hawaii, California, Connecticut, Michigan, Illinois, Indiana, Maryland, Colorado, Georgia, Oklahoma, Texas, and North Carolina.

Management’s Financial Responsibilities
Kickbacks:
 The management has the financial responsibility of ensuring ethical practice in patient referrals, and they are prohibited by the Act from soliciting payment or receiving money or property or remuneration as a reward for patient referrals. According to the Federal Anti-Kickback statute 42 U.S.C. § 1328-7b(b) of the Federal False Claims act, healthcare managers are prohibited from offering payment or solicitation or receipt of money, property or remuneration as a reward for patient referrals or the referral of health care services that are payable by a Federal health care program. The healthcare managers should act diligently in ensuring that the referrals made or accepted from other healthcare institutions are just and ethical as provided by the FCA. The healthcare managers are responsible for the kickbacks performed by their institution for improved Federal financing of healthcare packages like Medicare and Medicaid that help in the facilitation of equitable and quality health care for all.

Improper Financial Motive/Interest:
 According to the Federal Stark Law, 42 U.S.C. § 1395nn and 1396b, physicians within the healthcare system are prohibited from investment interests and the establishment of compensation arrangements in collaboration with health provision entities through patient referrals or payment of goods/services that are payable by Medicare or Medicaid. Patient referrals and goods/services should be evaluated frequently and scrutinized by healthcare managers to enhance accountability. They should ensure that the physicians or any other healthcare personnel do not interfere with the patient referrals or payment of goods or services to ensure that the Federal Medicare and Medicaid programs are protected from exploitation.

Verification of Pharmaceutical Supplies:
 The healthcare management has an obligation of presenting certified bills without alterations for payment by the government healthcare programs. All services listed for payment must be approved as medically necessary and as actual events. The managers are held by the government contract and therefore should not falsify the certification of these procurement processes. According to the FCA § 3729(b) (1), any claim to the government requires adequate knowledge requirements without reckless distortion or falsification of information. Healthcare managers are expected to undertake strict supervision and assessment of all procurement procedures to avoid falsification of information that is punishable by the Federal and State FCA (Legal Information Institute, 2017).

Consequences for Ethical or Legal Breach
In the case involving a whistleblower and eClinicalWorks (ECW), which is a vendor of electronic health records, the latter was ordered to pay a settlement of $155 million by the Department of Justice for violation of the False Claims Act and the Anti-Kickback Statute (McGovern, 2017, p1) This was a record recovery of state funds in Vermont. According to the FAC, the healthcare service providers have the responsibility of ethical procedures in government contracts, especially on the provision of information about their products. This case followed the violation of the Health Information Technology for Economic and Clinical Health Act of 2009 that dictates the necessity for technology vendors to adhere to standard product requirements for endorsement by the Department of Health and Human Services. ECW was accused of presenting false information about its products that did not meet the required criteria. The ECW software packages were below criteria, and the company was accused of violating the False Claims Act in its bid of seeking payment for the incentives. ECW agreed to settle the amount and signed a 5-year Corporate Integrity Agreement (CIA) as a commitment to quality assurance for the end-users of their software (McGovern, 2017, p1). I agree with this move made by the Justice Department as it acted as a caution for other health care vendors to be wary of the consequences of the lack of adherence to set standards of products and services. It also acted as a promoter of quality control in the health care sector for improved products and ethical practices for effective government healthcare expenditure, and accountability.

SmithKline Beecham Clinical Laboratories, Inc. was forced to pay $334 million to the government for defrauding Medicare, Medicaid, as well as other governme