HLTH 8301 Week 3 Discussion: Criminal Behavior by Healthcare Providers or Organizations
The United States federal government has created numerous programs to combat fraud and abuse in the healthcare industry. The government now encourages healthcare 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. The way a corporate compliance program is promoted within an organization can profoundly influence organizational culture.
Resources
Be sure to review the Learning Resources before completing this activity.
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 healthcare facility in which you are interested in working. The case you select should focus on 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 or civil 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 the About the Medicaid Fraud Control UnitsLinks to an external site. webpage and search for the area that provides more information about and links to each state’s Medicaid Fraud Control Unit.
- 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 (refer to “Compliance 101” in the Learning Resources) be of value in preventing or detecting and then correcting this criminal issue?
By Wednesday
Post your Discussion, to include the following:
- Briefly describe the case you selected and briefly describe the state and/or federal laws that are involved in your case. (If you are an international student, briefly describe the regional laws that are involved in your case.)
- Explain the ramifications of this criminal action or other action for the individuals and organizations involved (e.g., states working with the federal government in capturing fraud). Specifically, identify the penalties that resulted for individuals and organizations.
- Analyze the possible motivations behind the criminal act committed in the case you selected and how it relates to health care.
- Describe at least two basic ethical principles that may apply to this case.
- Finally, identify actions healthcare leaders can take to mitigate or prevent this type of issue.
Support your response by identifying and explaining key points and/or examples presented in the Learning Resources.
Read a selection of your colleagues’ postings. Consider how your colleagues’ postings relate to the information presented in the Learning Resources and to your own posting.
Refer to the Week 3 Discussion Rubric for specific grading elements and criteria. Your Instructor will use this grading rubric to assess your work.
By Friday
Respond to at least two of your colleagues’ postings in one or more of the following ways:
- Share an insight that you gained from having read your colleague’s initial post.
- Provide an additional perspective on what an administrator might do to prevent the situation your colleague described from happening or address it effectively once it is detected.
Continue engaging in the Discussion through Sunday.
SOLUTION HLTH 8301 Week 3 Discussion: Criminal Behavior by Healthcare Providers or Organizations
Hello Class,
Case Overview
In July 2024, Guardian Health Care Inc., Gem City Home Care LLC, and Care Connection of Cincinnati LLC, along with their parent company Evolution Health LLC, settled for $4.5 million to resolve allegations of violating the False Claims Act (FCA). The allegations centered on the companies providing illegal kickbacks to assisted living facilities and physicians in exchange for Medicare referrals. Between 2013 and 2022, these kickbacks included lease payments, wellness services, sports tickets, and meals. The companies subsequently billed Medicare for services rendered, which were deemed false claims due to the illegal inducements involved (U.S. Department of Justice, 2024)….
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