Impact of Healthcare Qui Tam on Healthcare Organizations

Impact of Healthcare Qui Tam on Healthcare Organizations

Understanding Qui Tam in Healthcare

People working for companies which are responsible for bill submission to government medical programs like Medicaid or Medicare, often find themselves as victims to joblessness, harassment or discrimination when they report probably fraud bills to the management. In order to ensure that such things do not happen, there is legal statute which is targeted towards provision of job protection and possibly rewards money to the victims if they follow legal channels.

Commonly known as the Qui Tam Statute, this law provides the ability to a person for suing a suspected company or person that might be submitting fake bills to government knowingly. Moreover, the Act is also directed towards protection of plaintiffs against any inappropriate actions by the employers.

Evaluating Impact on Healthcare Organizations

Becoming a Qui Tam plaintiff does not have any special requirements; the only requirement is that one has relevant information. In this case, a person could be defined as any legal entity, association, corporation, partnership or a natural person, and could also include a State or its subdivision. Once the whistle blower files a complaint a seal is placed on it to ensure that the investigation does not go public. Moreover, a copy of the complaint is also sent to the United States attorney general (Health Information Privacy, 2012).

After this step, the government requires an amount of 60 days along with good cause extensions for determining about the overall quality of the case and deciding whether they want to proceed further or not. In case the government decides to become a part of the ongoing case, the whistle blower is entitled to reception of 15-25% of any recovered amount. In a case where the Government backs off, it is up to the whistle blower about continuing ahead with the case or leaving it (Showalter, 2004).

Role of Government's False Claims Act

False Claims Act (FCA) is used as the best available weapon by the federal government when it comes to cases of fraud and abuse. As per the guidelines of this act, a person could be held responsible for penalizing provided that:

The person either presents or causes to present fraudulent or false approval or payment claims to United States government regardless of knowledge about its falsification.

The person has knowledge and still uses, produces or causes to be used or produced a fraudulent statement or record for getting a fraudulent or false claim approved or paid by United States government.

The person develops a conspiracy for defrauding the government through receiving fraudulent or fraud claim paid or allowed.

The person has knowledge and still uses, produces or causes to use or produce a fraudulent statement or record for decreasing, avoiding or concealing a transmission or payment obligations or property or money to the government (Showalter, 2004).

Due to the above mentioned requirements, the providers of healthcare and the people in power are required to have appropriate systems operating for verification of the organizational claims' ...