Law and ethics
Criminal Behavior by Health Care Providers
The United States federal government has created numerous programs to combat fraud and abuse in the health care industry. The government now encourages health care facilities to have a corporate compliance program, a plan that reduces the chances that the facility will violate laws or regulations. A corporate compliance program is an organization-wide program comprising a code of conduct and written policies, internal monitoring and auditing standards, employee training, feedback mechanisms, and other features, all designed to prevent and detect violations of governmental laws, regulations, and policies. It is a system or method ensuring that employees understand and comply with laws that apply to what they do every day.
To Prepare for This Discussion:
Conduct an online search to find a legal case, journal article, or detailed news article that describes a recent criminal case involving the kind of health care facility in which you are interested in working. The case you select may involve fraud or abuse (such as defrauding the Medicare or Medicaid programs, the Stark self-referral law, anti-kickback statute, or price-fixing) or other criminal act, such as patient abuse, murder, or theft. Evaluate the laws that are involved in your case, and consider the ramifications of this criminal action on the individuals and organizations involved.
A good source for cases is the Medicaid Fraud Control Unit. Consider looking through one or two state websites, which can be accessed at:http://www.namfcu.net/states.
As you analyze your case and prepare for the Discussion, consider possible motivations behind this criminal act. What could an administrator do to prevent this from happening or to address it effectively once it is detected? Would a compliance program (see “Compliance 101” in this week’s Learning Resources) be of value in preventing or detecting and then correcting this criminal issue?
Briefly describe the case you selected. Evaluate the state and/or federal laws that are involved in your case. (If you are an international student, evaluate the regional laws that are involved in your case.) Then explain the ramifications of this criminal action for the individuals and organizations involved (for example, states work with the federal government in capturing fraud).