Module #3 (B) Discussion – False Claims Act – Outcomes for System, Providers and

Module #3 (B) Discussion – False Claims Act – Outcomes for System, Providers and Patients
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Overview
The False Claims Act of 1863 became commonly relevant to health care with the rise of government funded health care programs. The two major government programs Medicare and Medicaid came into existence in 1965. The False Claims Act is the major tool in the government’s toolbox to go after fraudsters preying on these and other government programs. In layman’s terms, the False Claims Act gives the government the right to pursue criminal and civil charges for those that presented fictitious and inaccurate claims. For this discussion, you will continue your exploration of government websites in order to respond to the discussion prompt, which is based on the case scenario presented below.
Case Scenario
You work in a provider system. One of the providers in the system has been found guilty of submitting false claims for the last 5 years. The government has determined that the controls to prevent or detect fraud in the provider system are weak. As a result of weak controls, other claims need to be probe tested and reviewed via an audit. The claim set selected/ pulled by the government includes some claims submitted to Medicare, on your patients, for services you performed. You were told the Office of Inspector General is involved and you will be hearing more in the near future and as needed.
Shocked and surprised by all this, you start asking for clarification within your organization and quickly learn your organization has no Compliance Officer or staff to consult. The provider system seems to have no resources to train you and though you did received 30 minutes of voluntary annual compliance training from a vendor, an audit situation was not discussed. You begin doing some self research on the False Claims regulations to try to better understand this situation.
Write a 2 part discussion post that includes:
Your thoughts about how you feel learning that the organization did not invest in having a Compliance Officer or staff. Speculate what other concerns you may have about your patients and/ or your career if the tone at the top of the organization is lacked when it comes to compliance.
Speculate on how false claims will inflate the national cost of healthcare, harm patients and divert precious resources away from those that need care.