The False Claim In The Healthcare Industry
Introduction
The healthcare industry is one of the most diverse and highly regulated industry in the United States. The ability to manage the varied finance decisions of the organization and abide by the various laws is the high-wire gymnastics that has to be navigated by a healthcare administrator. In order to be effective one must first understand the varied pitfalls that exist to derail and endanger a healthcare facility. We will examine these in detail.
False Claims Act (FCA):
The False Claim Act was enacted to enable the federal government to civilly receive damages from a fraudulent claim by an organization. Claims for civil remedy has become more prevalent in healthcare because of the amount of money that is now involved through …show more content…
To seek remedy for fraudulent claims under the act, five elements must exist for the establishment of a false claim are (Cohen Seglias, Pallas Greenhall & Furman PC, 2014): 1) A claim for money must have been made, 2) claim made directly to the government or government contractor, 3) the claim was false, fictitious and/or fraudulent, 4) claim was submitted with knowledge that it was false, fictitious and/or fraudulent and it was deliberate, and 5) the claim was material (substantial). Unlike criminal cases where a higher burden of proof is needed, the government entity or the Department of Justice need only to present a preponderance of evidence like any other civil …show more content…
They promote prevention, detection and resolution of instances of conduct that do not conform to federal and state law, health care program requirements, and the hospital’s ethical and business policies. The existence of an effective compliance program may determine the level of sanctions, penalties and exclusions that will be imposed on the health care provider. A comprehensive compliance program should have 1) written policies and procedures which are distributed to all employees 2) a designated chief compliance officer 3) development and implementation or regular education and training or employees 4) a process to receive complaints and policy to protect whistle-blowers 5) regular audits and evaluations techniques to monitor compliance 6) policy regarding investigation and remedy of identified issue and guidelines concerning retention or non-retention of sanctioned employee (Ronald L. Scott,
The healthcare industry is one of the most diverse and highly regulated industry in the United States. The ability to manage the varied finance decisions of the organization and abide by the various laws is the high-wire gymnastics that has to be navigated by a healthcare administrator. In order to be effective one must first understand the varied pitfalls that exist to derail and endanger a healthcare facility. We will examine these in detail.
False Claims Act (FCA):
The False Claim Act was enacted to enable the federal government to civilly receive damages from a fraudulent claim by an organization. Claims for civil remedy has become more prevalent in healthcare because of the amount of money that is now involved through …show more content…
To seek remedy for fraudulent claims under the act, five elements must exist for the establishment of a false claim are (Cohen Seglias, Pallas Greenhall & Furman PC, 2014): 1) A claim for money must have been made, 2) claim made directly to the government or government contractor, 3) the claim was false, fictitious and/or fraudulent, 4) claim was submitted with knowledge that it was false, fictitious and/or fraudulent and it was deliberate, and 5) the claim was material (substantial). Unlike criminal cases where a higher burden of proof is needed, the government entity or the Department of Justice need only to present a preponderance of evidence like any other civil …show more content…
They promote prevention, detection and resolution of instances of conduct that do not conform to federal and state law, health care program requirements, and the hospital’s ethical and business policies. The existence of an effective compliance program may determine the level of sanctions, penalties and exclusions that will be imposed on the health care provider. A comprehensive compliance program should have 1) written policies and procedures which are distributed to all employees 2) a designated chief compliance officer 3) development and implementation or regular education and training or employees 4) a process to receive complaints and policy to protect whistle-blowers 5) regular audits and evaluations techniques to monitor compliance 6) policy regarding investigation and remedy of identified issue and guidelines concerning retention or non-retention of sanctioned employee (Ronald L. Scott,