Federal Health Programs (FHP)
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The False Claims Act (FCA) consists of penalties for or suits against healthcare organizations regarding the many aspects of the billing and coding procedures for Federal Health Programs (FHP).1 The FCA is a fraud prevention measure applied to the healthcare sector. This act is intended to make illegal the intentional, deliberately ignorant, or reckless stealing of funds for medical programs.1 Healthcare organizations, and HIM professionals that defraud the government are liable for all damages occurred with a five year prison sentence and the greater of $250000 or double the cost in damages.1
The billing data consists of the EMR, any documentation regarding procedures, and codes generated by HIM professionals after procedure. These different pieces of information need to be consistent with each other and with the procedures that were delivered by the healthcare organization for proper billing.
Within scenario 5-A the HIM professional recognizes that there is a mismatch in proper documentation of a procedure, leading to work that was being completed without proper payment.1 This HIM professional could be in an employment ending position if the practitioner insists on defrauding the government. This is where rigorous procedure and hearty policy determine clarity on ethical and professional wrong doings. If the HIM professional has in place proper rigorous policy and unwavering dedication to procedure then the HIM professional should be able to effectively produce either a Qui Tam suite or if the HIM professionals integrity was compromised a Voluntary Disclosure suit.1
The request to up-code encounters from the past month to make up for a deficit is unethical and should be reported. The issue for coders is to be as accurate as possible.1 This operation should be considered almost the same as an audit from a third party. In the case in which an executive staff is persuading an employee to abuse the medical system and defraud the government of money. This could lead to you owing a large sum on money in the case of a HIPAA violation, which for each claim that resulted in a greater payment shall be subject to a payment of not more than $10,000.1
. Harman LB, Cornelius FH. Ethical Health Informatics: Challenges and Opportunities. 3rd ed. Kindle ed. Burlington, MA: Jones & Bartlett Learning; 2017.
The False Claims Act was birthed during the Civil War in 1863 and acted as a combatant against defense contractor fraud. According to the Department of Justice’s website, “Any person who knowingly submitted false claims to the government was liable for double the government’s damages plus a penalty of $2,000 for each false claim.”1 This is a hefty price to pay and is meant to deter away the idea of anyone getting away with fraud. It is important for the government that no one is committing fraud or falsifying information against them because it could result in the government paying a substantial amount of money for resources that it may not need or that they might be paying way too much for.
Since the government may not have all the information or resources to catch every case of fraud, the provision of qui tam, or whistleblower, was incorporated and has remained in the False Claims Act since its beginning. This provision allows private citizens to file a case on behalf of the federal government. The False Claims Act Law Firm stated, “Private citizen-whistleblowers have proven to be a vital resource for the government,”2 which reveals how much the government relies on private citizens to help identify and call out potential cases of fraud. Whistleblowers can be awarded from 15% to 30% of the collected proceeds,3 which may inspire more private citizens to help out.
When in comes to policies and procedures around billing data, there are a few aspects to consider. The first two, and maybe the most important aspects are registering the patient and confirming financial responsibility. The billing process starts as soon as a patient schedules a visit with a doctor. Once information is shared about both the patient’s symptoms and their insurance, the biller must determine what is covered by the patient’s insurance and what should be billed to the patient.4 If any of this information, from what the patient gives to the healthcare service to what the patient is billed for, is falsified, many problems can arise creating an ugly situation. The False Claims Act allows fraud like this to be combated.
1) The False Claims Act. The United States Department of Justice. https://www.justice.gov/civil/false-claims-act. Published January 10, 2020. Accessed February 13, 2020.
2) Federal False Claims Act. False Claim Act Law Firm. https://www.falseclaimsact.com/federal-false-claims-act/. Accessed February 13, 2020.
3) What is the False Claims Act? National Whistleblower Center. https://www.whistleblowers.org/protect-the-false-claims-act/. Accessed February 13, 2020.
4) Writers S. The Medical Billing Process. MedicalBillingandCoding.org. https://www.medicalbillingandcoding.org/billing-process/. Published September 6, 2019. Accessed February 13, 2020.
Just as the HIPAA privacy rule and the HITECH Act provide guidance and incentives for HIM professionals to make ethical and legal decisions regarding protecting patient information, the False Claims Act provides similar aid in HIM decision-making. The 1986 False Claims Act forbids knowingly producing fraudulent claims to federal healthcare programs, especially towards Medicaid, under the threat of prison time and hefty fines (Harman & Cornelius, 2017). It is made clear that the Act does not penalize billing mistakes and simple negligence, but cases under review of the Department of Justice (DOJ) cover fraudulent claims that were made with awareness of the falseness of the claim and that the truth was ignored and/or disregarded.
The False Claims Actâ€s obvious role is to reduce healthcare fraud and abuse from healthcare programs and reduce unnecessary government spending through fraudulent reimbursements, but from the HIM professional standpoint the Act helps maintain the integrity of patient health data. If healthcare providers are dishonest or sloppy, they may inaccurately and untimely code diagnoses and services falsely (Harman & Cornelius, 2017). This is not only a disservice to the healthcare system but to the patient. The use of an incorrect diagnostic code for a patient or assigning codes for nonexistent diagnoses or procedures at one practice could affect their treatment at another practice if the initial diagnostic code is what the new location bases their decisions from (Prophet, 1997). Hence, it is crucial for HIM professionals to adhere to the False Claims Act and ensure that all types of codes and documentations concerning billing data are correct and timely. In addition, through the Qui Tam Statutes HIM professionals and other individuals have the freedom to whistle blow against potential fraudulent claims without fear of retaliation. Then the Voluntary Disclosure Protocol allows for self-reporting of fraudulent claims to reduce costly and disruptive full-scale audits (Harman & Cornelius, 2017). Through the False Claims Act, HIM professionals have clearer guidance in decision-making regarding policies and procedures around billing data.
Considering everything previously discussed about the False Claims Act if a medical executive staff requests to change data to up-code encounters from the past month to compensate for the reimbursement deficit on quarterly financials, then that is a definite violation of the Act. Not only is the up code untimely, the change of data is inaccurate and fraudulent and the medical executive staff is knowingly creating false claims to collect money not properly owed. It is up to that healthcare professional to stop and report their own fraudulent claim or for the HIM professional to report it.
Harman, L. B, and Cornelius, F. (2017). Ethical challenges in the management of health information (3rd ed., pp. 119-182). Burlington, MA: Jones and Bartlett Learning.
Prophet, S. (1997). Fraud and Abuse Implications for the HIM Professional. Journal of AHIMA 68, No.4, 68(4), 52â€“56. Retrieved from http://library.ahima.org/doc?oid=57611#.XkiwT2hKjI…
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