Dealing with Fraud in Health Care Organizations/ Institutions Essay Example

filed under seal restrict defendants from disclosing case details as mandated by Securities & Exchange Commission rules. Defendants must disclose any lawsuits that may impact their company according to Securities and Exchange Commission regulations. These actions can have economic consequences such as loss of customers and patient confidence. Settlements in these cases can amount to millions of dollars, significantly impacting a company's capital and profits. Fraudulent cases can also compromise data filing processes, leading to reduced efficiency and effectiveness for organizations. In the United States, there are four healthcare fraud cases affecting various healthcare organizations. The GlaxoSmithKline case (2010) is known as the largest healthcare fraud case in American history where this pharmaceutical giant paid a $3 billion settlement for both criminal and civil charges. Pfizer Inc. faced multiple allegations and settlements related to the drug Bextra, resulting in substantial fines.
Pfizer Inc. was accused of promoting Bextra for unapproved uses, making false claims about its safety and efficacy, and providing kickbacks to healthcare professionals. In 2009, the company reached a settlement for $2.3 billion which covered various drugs including Bextra, Geodon, Zyvox, and Lyrica. Specifically, Pfizer paid $1 billion in criminal fines for illegally marketing Bextra. These cases exposed fraudulent activities involving Medicaid fraud, false price reporting procedures, illegal kickbacks, off-label marketing practices,and failure to disclose important safety data by pharmaceutical companies. It is crucial that these companies are held accountable to protect public health and ensure fair business practices.

As a result of Pfizer Inc.'s improper marketing practices related to the drug 'Bextra', they admitted guilt and were fined $2.3 billion. This penalty included record-breaking amounts for both criminal charges ($1.2 billion) and civil fraud

in the United States. The misconduct violated the federal Anti-Kickback Statute 42(b) as well as the Federal Food Drug and Cosmetic Act (FDCA) regarding regulations on 'off-label' promotion.
Consequently, healthcare facilities have been receiving unwarranted reimbursements from State and Federal Government programs for their use of Bextra.
To comply with Medicare and Medicaid referral laws when admitting patients, these facilities must follow specific procedures.These procedures are heavily influenced by centers like Erickson/Sederstrom, which have been providing legal services to healthcare providers since 1967. The rules that healthcare facilities follow address various prerequisite requirements. These laws include the Physician Self-Referral Laws (Stark Law) and Anti-Kickback Statute, State and Federal Confidentiality laws, the Health Insurance Portability and Accountability Act (HIPAA), and the Emergency Medical Treatment and Active Labors Act (EMTALA), among others.

As Chief Nursing Officer, my main concern is ensuring compliance with the "Stark Law" regarding admissions. This law prohibits referring Medicaid and Medicare patients to healthcare facilities if there is a financial relationship between the referring physician and that institution. It is particularly important when physicians refer beneficiaries for one of the 10 designated categories of health services. Referring patients to an institution with which they have a financial affiliation would be considered illegal.

These laws play a crucial role in protecting patient health and preserving Federal funding measures (John C., 2013). According to the Health Care (Consent) and Care Facility (Admission) Act of 1996, there are no issues related to the Stark Law. Patients can be categorized as either "major" or "minor" healthcare based on significant differences between them.In order to facilitate admission purposes, necessary documents such as photocopies of valid CGHS cards, request letters, and permission letters

would be obtained from family members or representatives. For child patients, consent from an adult would be required, while personal consent would be needed for adult patients. Additionally, an advanced directive and representative agreement would need to be executed.

To address incidents of fraud and their impact on reproduction and birth issues, it is recommended to implement a corporate integrity program. Corporate Integrity Agreements (CIAs) are increasingly being used to combat healthcare fraud and include mandates such as appointing compliance officers, providing employee training, and establishing a communication hotline.

CIAs are crucial for institutions and facilities as they hold individuals accountable and receive attention from top management. Compliance officers play a vital role in effectively addressing fraud cases in healthcare facilities by ensuring that healthcare services, products, and materials meet the standards set by Medicaid, Medicare, and Federal Healthcare statutes specifically regarding reproduction and birth issues.

Collaboration between government entities and private industry has the potential for improvements in addressing operational challenges related to Confidentiality, Integrity, and Availability (CIAs) within the healthcare sector.The collaboration between healthcare professionals and patients leads to improved protection of patient health regarding reproductive and birth issues, as stated in the Health Law of 1967. To ensure patient information is safeguarded, it is crucial to develop a comprehensive plan that complies with relevant laws. The importance of privacy policies between doctors and patients is emphasized by the requirement for medical professionals to uphold the Hypocritical Oath. However, there are exceptions within the law that allow for disclosure of a patient's health information without their explicit consent. These exceptions include situations related to payment purposes, healthcare operations, and treatment intentions. Additionally, disclosures may occur for

Public Health activities such as reporting abuses, domestic violence cases, and neglect incidents. Furthermore, disclosure may be necessary for administrative and judicial proceedings or when preventing serious threats to client safety and well-being. Patients have individual rights that provide them with protection. These rights include the ability to request restrictions on disclosure; receive confidential information; copy and inspect protected health data; obtain an account of all disclosures concerning their health information; as well as acquire a copy of the provided notice.
The importance of maintaining patient-doctor confidentiality cannot be overstated when it comes to protecting different types of information in accordance with relevant laws (Barry, 2012). In summary, legal policies within the Healthcare sector effectively tackle fraudulent activities in healthcare facilities. However, although the Stark law helps decrease instances of fraud, it also has negative financial and professional impacts on health institutions.