The paper is devoted to the most common issues of non-integrity faced by the medical care provision institutions and gives a deeper insight into what these concepts mean and how they may be fought. The most widely spread misdeeds of the medical care personnel include fraud, waste and abuse. According to the information given out in the simulation, fraud constitutes unlawful alterations of the price for medical services or for drugs, in the result of which the doctor or a representative of a medical care institution benefits from the action financially and gets the part of money difference to his or her own pocket.
Waste is the action of spoiling or wasteful usage of medical equipment or drugs that are not prescribed or are recommended in smaller doses (either using them for individual purposes thus creating financial damage for the medical institution). Abuse is a more general notion that includes any action that appears to be not professional, involves neglecting the individual medical responsibilities, promises or direct professional functions at the workplace (Preventing Fraud, Waste and Abuse, 2009). All these malfunctions are interconnected and are seriously punished by a series of laws that will be discussed further.
Surely, the way of organizing the working process cannot be absolutely ideal – there are always individual peculiarities of the personnel, particular conditions that allow some deviations from norms, etc. However, the medical care institute is a social institution that bears the overall responsibility for the health status and level of well-being of the whole nation. Thus, it has to be taken special care of in order to avoid discrediting or reputation spoiling.
Besides, an important issue connected with the present topic is a set of privileges, subsidies and discounts people have according to their insurances or belonging to certain vulnerable groups of the population, thus having the right to enjoy certain medical services for free or at a lower price. In connection with this issue, the actions of fraud have gradually developed – the actions are known under the name of false claims, kickbacks, etc. It is because of these benefits being taken over by the citizens that a set of governmental regulations have been established to sustain the medical care provided on an adequate legal basis.
The first topic to be discussed in the context of the simulation is the set of key compliance processes that have to be taken into consideration while studying fraud, waste and abuse in the medical care sphere. The controlling body monitoring the compliance processes is the compliance officer or the compliance committee. His/her duties are focused on such issues as monitoring the compliance with the ethics code, reporting compliance incidents, overseeing compliance training and developing as well as implementing a compliance reporting system, and performing internal audits within the medical care institution. One more responsibility is to track the alleged cases of fraud and waste and to report them to the corresponding authorities (Preventing Fraud, Waste and Abuse, 2009).
The role of compliance processes monitoring is very important in every medical care institution, especially those receiving governmental grants for the provision o medical care.
“Universities and healthcare organizations that receive federal research grants have institutional review boards (IRBs) – that is, groups that review the proposed research for compliance with the federal regulations governing research involving human subjects. IRBs are composed of researchers, nonresearchers, and representatives from the community at large” (Issel, 2008).
Sometimes, in graver cases or in cases involving auditing of a large organization the compliance processes investigation may involve the participation of an outside auditor to provide “the financial statement information” (Finkler and Ward, 2006).
As one can see from the present overview, there is much to be paid attention to in the context of reviewing a medical institution for compliance with the accepted standards. In order to make the institution more complying and to avoid problems with the customers and the national law, all medical care establishments have to undertake continuous training procedures to ensure the high qualification of their personnel. Such training programs include the following elements.
First of all, all participants of the working process of the establishment (i.e. the working staff and patients) have to understand the full meaning of concepts of fraud, waste and abuse in order to be able to detect it if they appear its victims. After the initial acquaintance with the notions, they have to receive proper education on the code of ethics and the whole program of the institution pertaining to fraud, waste and abuse in order to be familiar with the legal position of the organization towards these and similar issues. A very important issue as well is the acquaintance with the obligations and responsibilities these participants have under the provisions of this Program, as sometimes the legal ignorance becomes the major reason for abuse and for non-detection of this abusive action.
The procedure of detecting and reporting the acts of fraud, waste and abuse is also included in the training course – since it is a socially significant action involving certain ethical and moral considerations, people have to know how to handle such a situation in order not to get in an awkward situation and not to gain the hostile attitude of colleagues or surrounding people. What is more important, people who are in this or that way included in the action and only suspect it but cannot prove it on certain evidence are often afraid to report these actions with the fear of being prosecuted themselves.
For this reason one of the aims of the training course is to explain the rights of the person reporting the misdeeds – it is essential to make people understand they will not be tried or questioned, and this report will not cost them their work. As soon as such reporting will be deprived of its negative connotation, then the rate of misdeeds’ disclosure is certain to rise. As the simulation also states, it is important to provide specific groups of medical care personnel with additional elements of training, namely those who deal with filing claims, dispensing drugs, billing-coding, sales and marketing of health care products and services (Preventing Fraud, Waste and Abuse, 2009).
Still, even under the conditions of strict control, auditing and training many cases of fraud, waste and abuse are detected. Hence, the governmental response is sometimes necessary – it includes a set of federal penalties (heavy financial penalties, exclusion from participating in Medicaid and Medicare, criminal prosecutions), punishment by state laws, investigations and prosecutions, law enforcement actions, audits and other means of preventing the misdeeds on a legal basis (Preventing Fraud, Waste and Abuse, 2009). The main law protecting medical care institutions from fraud is the False Claims Act of 2006 – it imposes different penalties for a series of crimes connected with false retribution requests. However, it is notable that the Act covers only those cases when the offender acts knowingly, i.e. intentionally illegally (The False Claims Act, n.d.).
In case the fraud, waste or abuse cases are still detected, one has to clearly realize that they involve a set of disciplinary procedures the gravity of which depends on the gravity of the offense. According to the information provided in the Simulation, the regular set of procedures includes re-training, moving the non-compliant employee to another position, reprimand or suspension (Preventing Fraud, Waste and Abuse, 2009).
Summing up everything that has been said about fraud, waste and abuse in the medical care institutions, it is vital to note that there is much being done to reduce the rate of misdeeds of such character, comprehensive training programs provide for the high-quality multi-faceted knowledge of all implications of such cases as well as ways to avoid and detect them. Besides, the issue has a sound legal basis that is applied to impose legal penalties on offenders, so it is possible to admit that the level of fighting misdeeds of this kind is rather high, providing the medical care institutions with a set of reasonable solutions.
Bibliography
Finkler, A., and Ward, D.M. (2006). Accounting fundamentals for health care management. Jones & Bartlett Publishers, 198 pp.
Issel, L.M. (2008). Health Program Planning and Evaluation. Jones & Bartlett Publishers, 594 pp.
The False Claims Act (n.d.). Web.
Week 3 Fraud Simulation (2009). University of Phoenix, 41 pp.