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    Case: Criminal Behavior by Healthcare Provider

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    The United States federal government has created numerous programs to combat fraud and abuse in the health care industry. The government now encourages health care 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 case you select may involve 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 action on the individuals and organizations involved.

    Teitelbaum J., & Pozgar G. (2015). Law, ethics, and policy in healthcare administration (Custom ed.). Burlington: Jones & Bartlett Learning.
    o Chapter 7, "Government Ethics and the Law" (pp. 236-254)
    o Chapter 9, "Physician Ethical and Legal Issues" (pp. 299-323)
    National Association of Medicaid Fraud Control Units. (n.d.). NAMFCU participating states. Retrieved from http://www.namfcu.net/states
    United States House of Representatives. (n.d.). Find your representative. Retrieved from http://www.house.gov/representatives/find/
    U.S. Department of Health and Human Services. (n.d.). Compliance 101. Retrieved from http://oig.hhs.gov/compliance/101/index.asp

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    Solution Preview

    Step 1
    The case I have selected is a fraud case. It is the Columbia/HCA fraud case. It is one of the largest examples of Medicare fraud in US history(a). The frauds uncovered at Columbia/HCA were doctors being offered financial incentives to bring in patients, falsifying diagnostic codes to increase reimbursements from Medicare and other government programs, and billing the government for unnecessary lab tests (b). After Federal Agents collected evidence, the HCA pled guilty to more than a dozen criminal and civil charges and paying fines totaling $1.7 billion in 1999.

    Step 2
    The laws that are violated by Columbia/HCA are knowingly and willfully offering, paying, soliciting or receiving remuneration directly or ...

    Solution Summary

    This posting gives you a step-by-step explanation of criminal behavior by healthcare provider . The response also contains the sources used.