Fraud and Abuse: Marcus Welby Healthcare Corporation
In the healthcare sector, fraud and abuse can take many forms among patients, healthcare providers, and their party organizations such as Insurance companies and suppliers (Bush et al., 2017). The healthcare provider may experience multiple types or get involved in multiple types of fraud in their professions. Some of the cases of fraud and abuse among healthcare providers include billing for service not provided, billing duplicate for the same service at different times, billing for a more costly service than the one provided, and billing for a covered service when a non-covered service is the one that has been provided. Additionally, healthcare providers can also provide false diagnoses, accept a kickback for patient referrals, order excessive/inappropriate tests, prescribe not medically necessary medicines, or prescribe medicine for use by other people than the patient. On the other hand, a patient can experience or get involved in fraud in different forms (Bush et al., 2017). Some cases where a patient can get involved in fraud include filing claims for services /products not received, forging receipts, and obtaining medications that are not needed for personal gain. A patient can also be involved in fraud by providing false information to apply for services, using someone else’s insurance coverage for services, or illegally visiting multiple physicians to obtain multiple prescriptions. An insurance company can also get involved in fraud in different ways, such as overstatement of the insurer’s cost when paying a claim, misleading enrollees about health plan benefits, denying valid claims, or undervaluing the amount owed the insurer to a health care provider. All these fraud and abuse cases have severe legal consequences that impact professional practices in a healthcare facility (Bush et al., 2017). The case study reveals a potential risk of exposing the stakeholders: patients, healthcare providers, and Insurance companies working together with Marcus Welby Hospital to legal, ethical issues related to fraud and abuse. This article evaluates the hospital’s potential fraud and abuse practices and provides advice for the stakeholder to prevent exposing themselves to bribery and corrupt practices.
The current anti-bribe and anti-corruption laws prevent and enforce hospital and healthcare facilities against corruption and bribery by imposing fines and penalties from different bribery and corrupt practices (Garlach et al., 2007). For instance, the laws prohibit companies and individuals from engaging in bribery related to any sale and purchase transaction in healthcare. The laws completely prohibit the manufacturer, trading enterprise, and medical care facility from offering off-the-contract or off-the-book kickbacks during sales and purchase transactions. Kickback refers to any payment, reward, or compensation that any party in the sale and purchase transaction can use to influence the other party to engage in a corrupt bidding scheme (Garlach et al., 2007). It can involve giving funds, offering property, or other surplus benefits to the contracting party to influence their selling/purchasing decision. Therefore, when Marcus Welby hospital offers a premium to its clients when they order DME from its subsidiary, it may influence their purchases by forming a corrupt bidding scheme. To avoid this kickback, I would recommend the hospital ensure that all the premiums/reward it offers to its client have very little monetary, commercial, or reimbursement value that does not influence/corrupt their purchasing decisions. In other words, the hospital should ensure that its premium does not have any significant benefits that may be considered improper (Garlach et al., 2007).
Marcus Welby Hospital Corporation needs effective promotion and marketing approaches to advertise and create awareness for its products and service to the public. One of the best ways to attract clients to purchase its product and use its service is to offer customers discounts. Nonetheless, it is also possible to engage in promotion activities that may seem improper and illegal. Therefore, it is paramount that when the hospital offers rebates to a patient who uses its equipment from the subsidiary, it should ensure that such an approach is only for promoting its products and not to improperly obtain customers or retain this business unit in return (Chen et al., 2020). It doe ensure that it only acts as a sale representative or distributor. The Medical equipment subsidiary should also ensure that all the promotion activities through Marcus Welby Healthcare Hospital are well supervised to prevent any improper practices intended to negatively obtain clients for the hospital or the subsidiary. This will allow the corporation to use its promotion to legally market its product and services effectively and eliminate the risk of breaching the anti-bribery and anti-corruption laws.
When the subsidiary pays the hospital and home health agency personnel for assisting patients in learning how to use its products and alter the arterial blood gas test result to facilitate Medicare payment for oxygen concentrators, it risks exposing the corporation to commercial opportunities for corruption and bribery. First, the healthcare in the hospital may choose to teach a patient how to use the product just for the mere intention of getting paid for doing so. Secondly, when the subsidiary alters the arterial blood gas test, the intention is to get financial benefits improperly. These two practices can be viewed as an opportunity for corruption and bribery (Chen et al., 2020). Therefore, the corporation needs to ensure that when it compensates the healthcare providers or seeks insurance cover for its products, it uses legitimate activities that only indicate non-corrupt purposes. In a nutshell, the corporation should have a comprehensive system of written policy, training, and procedures and monitor/audit all functions to ensure that all stakeholders’ due diligence and comply with the anti-bribery and anti-corruption laws effectively (Chen et al., 2020).
References
Bush, J., Sandridge, L., Treadway, C., Vance, K., & PH, C. D. (2017). Medicare fraud, waste, and abuse.
Chen, Z. X., Hohmann, L., Banjara, B., Zhao, Y., Diggs, K., & Westrick, S. C. (2020). Recommendations to protect patients and health care practices from Medicare and Medicaid fraud. Journal of the American Pharmacists Association, 60(6), e60-e65.
Gerlach, P. V., Shubert, L., & Zhengyu, T. (2007). US and PRC anti-bribery laws: regulation, risk, and prevention in the life sciences. Life Sciences, 08.