Course Objective for Assignment:
· Identify and apply ethical principles to the management and delivery of health care.
· Recommend structures and processes to manage compliance and to address ethical concerns in health care organizations.
From the list below, choose one topic related to financial management in health care organizations. Include a cover page and a list of references at the end of the paper in APA Format. Paper will be double spaced and be 4-5 pages in 12 point New Times Roman font.
TOPICS
· False Claims Act
· Physician Self-Referral Act (Stark Law)
· Anti-kickback Statute
· Civil Monetary Penalties Law
· Exclusion Authorities
· Tax Exemption (Non-profit Hospitals)
· Anti-trust & Accountable Care Organizations
· Deficit Reduction Act
The assignment is to be written in clear, concise narrative. All sections in the outline for Assignment #2 are required.
Outline: Must use the headings from the outline below in your paper and the paper must be in narrative form not outline or bullet format. A penalty will be deducted from paper if underlined headings not used in your paper.
1. Name of the Law and or laws:
State the official title of the federal and/or state law, the statute and section number. Must be either a federal statute or state statute and you must cite both if applicable. Thus if there is both a federal and state law that covers your subject picked then you must cite both. Do not assume that there is just a federal and or state law. In most cases there is both a federal and state law. You must use the laws cited in this section throughout the rest of the paper.
2. Management’s Financial Responsibilities:
What are the health care organization’s responsibilities under this financial management statute you stated above? Provide a comprehensive discussion of three (3) specific responsibilities under the financial management statute. State specifically after each responsibility where this responsibility is stated in the federal or state law. Describe the appropriate behavior and expectation. Include the citations and source of documents describing the organization’s responsibilities.
3. Consequences for Ethical or Legal Breach:
Discuss in general the civil and criminal consequences from the law. Then identify from the news, three (3) specific case examples of health care organizations or health care providers found guilty of a legal or ethical breach relative to the law you have cited in first part of paper. Identify the specific legal and/or ethical breach and the penalties assessed to the health service organizations and/or individuals found guilty of violating the law or ethics [provide citation of law]. At the end of each case, discuss in detail whether you agree or not with the decision and why. Bring in the facts of the case to support your comments. Students should use a minimum of three (3) documented specific examples retrieved from the print media.
4. HCO Management’s remedial steps to reverse the non-compliance organizations:
Describe in detail three (3) specific management actions or remedial steps you would take to ensure the financial management in the health care organization meets or exceeds the federal law or state law relative to the requirements of the law you cited above. Discuss specifically how each of the three management actions specifically meets or exceeds the specific federal or state law you cited. Note: These actions may include specific uses of technology, procedures, human resource training, and other management tools. However these action steps must be within the control of a manager.
5. Conclusion: Summary your findings above
6. Reference List [APA Format]
The paper must be:
· Be sure and use the underlined headings found in the outline below in your paper. Paper must be in narrative format not outline or bullets.
· Include a cover page [not counted as a page] which should have student name and title of your paper [Provide a short name for the legal responsibility the specific health care organization has for one type of patient right in a specific setting ]
· A the end of the paper a list of references in APA Format [not counted as a page]
· Be prepared using word-processing software and saved with a .doc, .docx, or .rtf extension. No pdf.
· Must cite to the source for all your facts in the text of your paper in APA format.
GOVERANCE AND FRAUD IN HEALTH
CARE ORGANIZATIONS
Legal and Ethical Responsibilities
Mervyn Riley
Fall 2018
Submitted to
Professor Nicole Mazzei-Williams
In Partial Fulfillment of HMGT 372
This study source was downloaded by 100000766134782 from CourseHero.com on 05-24-2022 16:54:56 GMT -05:00
https://www.coursehero.com/file/34694805/Assignment-2-Goverance-and-Fraud-in-Health-Care-Organizations-ansdocx/
https://www.coursehero.com/file/34694805/Assignment-2-Goverance-and-Fraud-in-Health-Care-Organizations-ansdocx/
1. Name of the Law and or laws:
U.S. Code › Title 31 › Subtitle III › Chapter 37 › Subchapter III › § 3729
31 U.S. Code § 3729 – False claims
The Office of the Inspector General can pursue financial penalties for organizations and can
exclude them from numerous types of activities. They have the authority to fine an organization
for several different amounts. These amounts are varied because of the type of violation that is at
hand $10,000 to $50,000 per violation. These penalties would be specific in nature and have a
fine attached to the violation. These penalties are assessed on an individual basis.
A company can be found in violation of the False Claims Act if they knowingly present
fraudulent billing statements, make false statements or present false records in the request of
claim. They are also found liable if they have been found to violate any of the other provisions in
the law that all are in relation to false claims, false billing and false reporting in a conscious to
benefit financially from a conscious false report. It is also important to note that the penalties that
are assessed are adjusted annually for inflation. This means that these penalties will continue to
increase.
2. Management’s Financial Responsibilities:
Accurate Coding and Billing
31 U.S. Code § 3729 in Section A. addresses liability for certain acts to include ‘knowingly
presents, or causes to be presented, a false or fraudulent claim for payment or approval’[Law].
Agency management has the responsibility to the consumers and the payor to do their due
diligence in their reporting. Management has the responsibility to control the documentation that
is submitted as the support for the claims that are submitted to the insurance company for
1 | P a g e
This study source was downloaded by 100000766134782 from CourseHero.com on 05-24-2022 16:54:56 GMT -05:00
https://www.coursehero.com/file/34694805/Assignment-2-Goverance-and-Fraud-in-Health-Care-Organizations-ansdocx/
https://www.coursehero.com/file/34694805/Assignment-2-Goverance-and-Fraud-in-Health-Care-Organizations-ansdocx/
payment. The management has the responsibility to make sure that the services that are provided
are deemed to be medically necessary, the services are cost-effective and there is a high level of
quality care. The management must be able to identify services that have been delivered and be
able to give a description of the service that was rendered to the consumer. This description is the
support for claims that are submitted to the insurer for payment. You control the documentation
describing what services they received, and your documentation serves as the basis for claims
sent to the insurer for services provided.
Physician Documentation
31 U.S. Code § 3729 in Section A. addresses liability for certain acts to include ‘knowingly
presents, or causes to be presented, a false or fraudulent claim for payment or approval’ (U.S.
Code › Title 31 › Subtitle III › Chapter 37 › Subchapter III › § 3729). Management is tasked with
maintaining the exact and concise medical documents that outline the services that have been
provided to consumers. The management is also charged with making sure that there is proper
documentation by the physician that can be submitted to support claims that are submitted to the
insurer. These documents also allow the agency to ensure that the proper treatment services are
providing for consumers for whom they provide services. These accurate notes ensure that other
providers across the network of providers that may share medical information are able to be
factually correct when they submit billing after providing appropriate services.[Precautions]
Physician Investments in Health Care Business Ventures
31 U.S. Code § 3729 in Section E addresses any person who is authorized to make or deliver a
document certifying receipt of property used, or to be used, by the Government and, intending to
defraud the Government, makes or delivers the receipt without completely knowing that the
2 | P a g e
This study source was downloaded by 100000766134782 from CourseHero.com on 05-24-2022 16:54:56 GMT -05:00
https://www.coursehero.com/file/34694805/Assignment-2-Goverance-and-Fraud-in-Health-Care-Organizations-ansdocx/
https://www.coursehero.com/file/34694805/Assignment-2-Goverance-and-Fraud-in-Health-Care-Organizations-ansdocx/
information on the receipt is true[Law]. In this instance the management responsibility is to use
all resources that are available to make certain that the services that they are requesting payment
for are all true. Physicians that are invested in external healthcare services such as an MRI center
or any other type of service provider can be guided to refer or deliver services based on their
financial interest and investment. Management must make sure that these sorts of relationships
do not cause them to deliver and submit fraudulent billing for unnecessary services[Precautions].
3. Consequences for Ethical or Legal Breach
The Office of Inspector General (OIG) has the authority to seek civil monetary penalties (CMPs),
assessments, and exclusion against an individual or entity based on a wide variety of prohibited
conduct. In each CMP case resolved through a settlement agreement, the settling party has
contested the OIG’s allegations and denied any liability. No CMP judgment or finding of liability
has been made against the settling party (oig.hhs.gov, 2017).
The Office of Inspector General (OIG) Enforcement Cases
08-21-2018
Oklahoma Prosthetics Supplier Excluded for Default
On August 21, 2018, OIG excluded La Fuente Ocular Prosthetics, LLC (La Fuente), an
Oklahoma City, Oklahoma, prosthetic supplier, for defaulting on payment obligations under a
settlement agreement with OIG wherein OIG alleged that La Fuente submitted false or
fraudulent claims to Medicare and created false records material to a false claim. La Fuente’s
exclusion will remain in effect until it cures the default of its payment obligations and OIG
reinstates La Fuente’s participation in Federal Health care programs. Senior Counsel Geoffrey
Hymans represented OIG[Cases].
3 | P a g e
This study source was downloaded by 100000766134782 from CourseHero.com on 05-24-2022 16:54:56 GMT -05:00
https://www.coursehero.com/file/34694805/Assignment-2-Goverance-and-Fraud-in-Health-Care-Organizations-ansdocx/
https://www.coursehero.com/file/34694805/Assignment-2-Goverance-and-Fraud-in-Health-Care-Organizations-ansdocx/
The decision by the Office of the Inspector General to exclude La Fuente Ocular Prosthetics,
LLC (La Fuente) was warranted. La Fuente was found in violation because of false claim
submissions. La Fuente then decided to enter into an agreement of payment arrangements to
settle the cost of the violations. The default prompted the OIG to seek other methods of relief and
La Fuente was then excluded. Exclusion is an option to address violations of 42 U.S.C. § 1320a-
7(b)(7).
06-11-2018
Oklahoma Ambulance Authority Settles Case Involving False Claims
On June 11, 2018, Comanche County Hospital Authority d/b/a Comanche County Memorial
Hospital, (Comanche), Lawton, Oklahoma, entered into a $566,806 settlement agreement with
OIG. The settlement agreement resolves allegations that Comanche submitted claims to
Medicare for emergency ambulance transportation to destinations such as skilled nursing
facilities and patient residences that should have been billed at the lower non-emergency rate. In
addition, while OIG’s investigation, Comanche discovered and disclosed that it submitted claims
to Medicare for emergency ambulance transportation that were not medically reasonable or
necessary. Comanche also disclosed that it submitted claims to Medicare for transports where the
documentation for the transport was not consistent with the patient’s condition, and therefore did
not support the documented medical necessity for the transport. OIG’s Consolidated Data
Analysis Center and Office of Counsel to the Inspector General, represented by Senior Counsels
Geoffrey Hymans and Andrea Treese Berlin, collaborated to achieve this settlement.[Cases]
In the case of the Comanche County Medical Hospital, the judgement was warranted. The
hospital submitted claims that were fraudulent. The management has the responsibility to make
certain that the claims that are being submitted are right and truthful in the description of their
4 | P a g e
This study source was downloaded by 100000766134782 from CourseHero.com on 05-24-2022 16:54:56 GMT -05:00
https://www.coursehero.com/file/34694805/Assignment-2-Goverance-and-Fraud-in-Health-Care-Organizations-ansdocx/
https://www.coursehero.com/file/34694805/Assignment-2-Goverance-and-Fraud-in-Health-Care-Organizations-ansdocx/
services. This is in violation of U.S. Code › Title 31 › Subtitle III › Chapter 37 › Subchapter III › §
3729 Section B that addresses someone that knowingly makes, uses, or causes to be made or
used, a false record or statement material to a false or fraudulent claim.
11-04-2016
Physician Agrees to 20-Year Exclusion to Resolve Civil Monetary Penalty Case
Labib Riachi, M.D., a New Jersey based OB/GYN with a subspecialty in urogynecology, agreed
to be excluded from participation in Federal health care programs for a period of twenty years
under 42 U.S.C. § 1320a-7(b)(7) for allegedly violating the Civil Monetary Penalties Law. OIG
alleged that Dr. Riachi knowingly submitted claims to Medicare and Medicaid for pelvic floor
therapy services that he knew or should have known were not provided as claimed or were false
or fraudulent. These claims were not provided as claimed or were false or fraudulent for one or
more of the following reasons: (1) Dr. Riachi failed to personally perform or directly supervise
services while he was traveling outside the United States or State of New Jersey; (2) Dr. Riachi
failed to personally supervise the performance of a diagnostic procedure performed by his
medical assistants; (3) services were not actually provided; (4) physical therapy services were
provided by unlicensed and unqualified individuals; (5) services were not documented; and (6)
diagnostic services were not reasonable and necessary. David Blank, Tamara Forys, and Jennifer
Leonardis represented OIG with assistance from Paralegal Specialist Mariel Filtz. [Cases]
The agreed decision by the OIG and Labib Riachi, M.D was a correct decision in response to the
violations found by the OIG office and the number of violations. The OIG is empowered within
the law to be able to level financial penalties or seek exclusion.
4. HCO’s Management’s remedial steps to reverse the non-compliance organizations:
5 | P a g e
This study source was downloaded by 100000766134782 from CourseHero.com on 05-24-2022 16:54:56 GMT -05:00
https://www.coursehero.com/file/34694805/Assignment-2-Goverance-and-Fraud-in-Health-Care-Organizations-ansdocx/
https://www.coursehero.com/file/34694805/Assignment-2-Goverance-and-Fraud-in-Health-Care-Organizations-ansdocx/
Three steps that can be implemented to directly reverse the actions of a non-compliant
organization would a combination of technology and human interaction. Firstly, the
implementation of an Electronic Medical Records (EMR) system. This electronic system will
allow records to be entered easier and protect against loss and damage to information contained
on paper files and handwritten. In the event of this kind of document loss a provider might fill in
information that is fraudulent to make up for the lost information. The management would then
implement a two-signature verification process. This type of process can be assigned within the
EMR system. This would allow for two levels of scrutiny on every billing statement that leaves
the agency and no one person will have autonomy to bill in the system. This decreases the
likelihood of agency false billing submission. Lastly management would also implement a
quality control assessment periodically. This would focus on best practices and audit the
submission process in shorter periods so that the extent of liability would be limited and easier to
be remedied.
5.Conclusion:
The number of violations and exclusions that are being handed out by the OIG underscores the
need for accountability in the healthcare system. These abuses in the system are causing higher
service costs to consumers and operating costs to providers. It also represents a decreased ability
of the federal government to provide services due to funding unnecessary and false claims from
unsavory operators in the system that do not have the overall system sustainability at heart.
Technological advances and industry controls and accountability will allow for a market
correction that will augment quality care and affordability in the healthcare sector.
References
6 | P a g e
This study source was downloaded by 100000766134782 from CourseHero.com on 05-24-2022 16:54:56 GMT -05:00
https://www.coursehero.com/file/34694805/Assignment-2-Goverance-and-Fraud-in-Health-Care-Organizations-ansdocx/
https://www.coursehero.com/file/34694805/Assignment-2-Goverance-and-Fraud-in-Health-Care-Organizations-ansdocx/
AVOIDING MEDICARE FRAUD & ABUSE: A ROADMAP FOR PHYSICIANS. (2017, November). Retrieved from
Medicare Learning Network: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-
MLN/MLNProducts/Downloads/Avoiding_Medicare_FandA_Physicians_FactSheet_905645.pdf
Civil Monetary Penalties and Affirmative Exclusions. (2018, August 8). Retrieved from Office of the
Inspector General: https://oig.hhs.gov/fraud/enforcement/cmp/cmp-ae.asp
U.S. Code › Title 31 › Subtitle III › Chapter 37 › Subchapter III › § 3729. (n.d.). Retrieved from Legal
Information Institute : https://www.law.cornell.edu/uscode/text/31/3729
7 | P a g e
This study source was downloaded by 100000766134782 from CourseHero.com on 05-24-2022 16:54:56 GMT -05:00
https://www.coursehero.com/file/34694805/Assignment-2-Goverance-and-Fraud-in-Health-Care-Organizations-ansdocx/
https://www.coursehero.com/file/34694805/Assignment-2-Goverance-and-Fraud-in-Health-Care-Organizations-ansdocx/
8 | P a g e
This study source was downloaded by 100000766134782 from CourseHero.com on 05-24-2022 16:54:56 GMT -05:00
https://www.coursehero.com/file/34694805/Assignment-2-Goverance-and-Fraud-in-Health-Care-Organizations-ansdocx/
Powered by TCPDF (www.tcpdf.org)
https://www.coursehero.com/file/34694805/Assignment-2-Goverance-and-Fraud-in-Health-Care-Organizations-ansdocx/
http://www.tcpdf.org
5/16/22, 4:27 PM Assignment #1: Management Tools for Health Care Organizations to Comply with Patient’s Legal Rights (12.5 points) – HMGT 37…
https://learn.umgc.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=1267716&grpid=0&isprv=0&bp=0&ou=686368 1/5
Assignment #1 Rubric Revised
Course: HMGT 372 6380 Legal and Ethical Issues in Health Care (2225)
C
ri
t
e
ri
a
Outstanding 90-100% Superior 80-89% Good 70-79% Below Standard 60-69% Fai
P
r
o
p
e
r
T
it
l
e
s
f
o
r
L
a
w
s
&
L
e
g
al
O
b
li
g
a
ti
o
n
s
30 points
Relevant federal and state statutes
are all current and properly titled.
The research represents a
thorough canvass of the law and
secondary sources. Demonstrated
high degree of logic and reasoning
when discussing the law and
connecting to main points
regarding two (2) legal obligations.
26.7 points
Provided the proper title, statute
and section number of applicable
federal and state laws. And,
provided a comprehensive
discussion of two (2) specific legal
obligations from the federal and
state laws.
23.7 points
Provided the proper title, statute
and section number of applicable
federal law but not state law or vice
versa. Provided a limited discussion
of two (2) specific legal obligations
from federal and state law.
20.7 points
Provided the title but not the
proper statute and section number
of applicable federal and state laws.
Did not provide either the federal
or state law. Provided an
inadequate discussion of two (2)
specific legal obligations or only
discussed one legal obligation from
federal or state law.
10
Stu
ass
ele
att
to
5/16/22, 4:27 PM Assignment #1: Management Tools for Health Care Organizations to Comply with Patient’s Legal Rights (12.5 points) – HMGT 37…
https://learn.umgc.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=1267716&grpid=0&isprv=0&bp=0&ou=686368 2/5
C
ri
t
e
ri
a
Outstanding 90-100% Superior 80-89% Good 70-79% Below Standard 60-69% Fai
L
e
g
al
C
o
n
s
e
q
u
e
n
c
e
s
&
R
e
al
L
if
e
C
a
s
e
s
25 points
Student provided extensive
original analysis of civil/criminal
consequences and legal
obligations. Goes substantially
beyond points raised in classroom
reading and discussions. Student
has identified two (2) real life cases
that are precedent, seminal, or not
previously discussed in the
Discussion Boards by the student,
other students or the Professor.
22.25 points
Provided a comprehensive
discussion of general civil and
criminal consequences from
either the federal and/or state
law. Listed two (2) specific legal
obligations from federal and/or
state laws and discussed two (2)
real life cases.
19.75 points
Provided a limited discussion of the
general civil and criminal
consequences under the federal
and/or state law, listed two (2) legal
obligations under the federal
and/or state law, and/or provided
few details of one (1) real life case.
17.25 points
Provided a limited discussion of the
civil and criminal consequences
from either federal and/or state law
and/or failed to list the two (2)
legal obligations and/or an in
adequate discussion of one (1)
specific consequence, from federal
and/or state law, for each legal
obligation and/or provided few
details of one (1)real life case.
8 p
Stu
ass
ele
att
to
5/16/22, 4:27 PM Assignment #1: Management Tools for Health Care Organizations to Comply with Patient’s Legal Rights (12.5 points) – HMGT 37…
https://learn.umgc.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=1267716&grpid=0&isprv=0&bp=0&ou=686368 3/5
C
ri
t
e
ri
a
Outstanding 90-100% Superior 80-89% Good 70-79% Below Standard 60-69% Fai
M
a
n
a
g
e
m
e
n
t
A
c
ti
o
n
s
&
C
o
n
cl
u
si
o
n
15 points
Student offers original
contributions to the discussion of
three (3) management actions.
Management actions discussed are
related to each other in interesting
and creative ways with reference
to research. Thought provoking or
interesting conclusion that ties
everything together and furthers
the thesis of the paper.
13.35 points
Student discussed in detail three
(3) specific management actions
that he/she would institute to
ensure patients’ rights protected.
Provided a comprehensive
summary of findings.
11.85 points
Discussed in detail only two (2)
specific management actions that
he/she would institute to ensure
patients’ rights protected. Provided
a limited summary of findings.
9 points
Described in detail only one (1) or
no specific management actions
that he/she would institute to
ensure patients’ rights were
protected. Failed to adequately
summarize findings.
2 p
Stu
ass
ele
att
to
5/16/22, 4:27 PM Assignment #1: Management Tools for Health Care Organizations to Comply with Patient’s Legal Rights (12.5 points) – HMGT 37…
https://learn.umgc.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=1267716&grpid=0&isprv=0&bp=0&ou=686368 4/5
Total / 100
C
ri
t
e
ri
a
Outstanding 90-100% Superior 80-89% Good 70-79% Below Standard 60-69% Fai
A
tt
e
n
ti
o
n
t
o
I
n
s
tr
u
c
ti
o
n
s
C
la
ri
t
y
;
g
r
a
m
m
a
r
&
A
P
A
15 points
Student demonstrated a full
understanding of requirements;
responded to each aspect of
assignment: correctly developed
required document format
13.35 points
Student demonstrated general
understanding of requirements;
missed one minor aspect of
assignment; the document format
is missing one element
11.85 points
Student demonstrated some
understanding of requirements;
missed a key element or two minor
aspects of assignment; the
document format is missing two or
more elements
9 points
Student failed to show a firm
understanding of requirements;
missed two key elements or several
minor aspects of assignment; the
document format is not complete
or partially incorrect
0 p
Stu
un
req
is n
15 points
Student’s writing
is clear and easy
to follow;
grammar and
spelling are all
correct;
formatting gives a
professional look
and adds to
readability, no
APA style errors
13.35 points
Most ideas are
presented
clearly;
occasional
spelling and/or
grammar issues
(no more than 3),
attempts in-text
citation and
reference list but
1 or 2 APA style
errors are
present
11.85 points
Wordy; some
points require
rereading to
understand fully;
more than 3
occasional
spelling and/or
grammar errors,
attempts in-text
citation and
reference list;
APA style errors
are present;
inconsistencies in
citation usage
can be found
throughout the
document
9 points
Unclear and
difficult to
understand;
frequent spelling
and grammar
issues (more than
6), attempts
either in-text
citation or
reference list but
omits the other
0 p
Ve
un
po
ter
me
str
5/16/22, 4:27 PM Assignment #1: Management Tools for Health Care Organizations to Comply with Patient’s Legal Rights (12.5 points) – HMGT 37…
https://learn.umgc.edu/d2l/lms/dropbox/user/folder_submit_files.d2l?db=1267716&grpid=0&isprv=0&bp=0&ou=686368 5/5
Overall Score
Outstanding
90 points minimum
Superior
80 points minimum
Good
70 points minimum
Below Standard
60 points minimum
Failure
0 points minimum
Why Choose Us
- 100% non-plagiarized Papers
- 24/7 /365 Service Available
- Affordable Prices
- Any Paper, Urgency, and Subject
- Will complete your papers in 6 hours
- On-time Delivery
- Money-back and Privacy guarantees
- Unlimited Amendments upon request
- Satisfaction guarantee
How it Works
- Click on the “Place Order” tab at the top menu or “Order Now” icon at the bottom and a new page will appear with an order form to be filled.
- Fill in your paper’s requirements in the "PAPER DETAILS" section.
- Fill in your paper’s academic level, deadline, and the required number of pages from the drop-down menus.
- Click “CREATE ACCOUNT & SIGN IN” to enter your registration details and get an account with us for record-keeping and then, click on “PROCEED TO CHECKOUT” at the bottom of the page.
- From there, the payment sections will show, follow the guided payment process and your order will be available for our writing team to work on it.