Introduction
False claims filing compromises the hospital’s integrity and puts at risk its relationship with the patients who trust the healthcare professionals as representatives of the healthcare system. Therefore, it is essential to develop a hospital-wide policy to discourage and prevent false claims from being submitted. This policy aims to ensure all staff members are informed of their responsibility in detecting and preventing false claims and delineates relevant procedures regarding reporting.
False Claims Act
The False Claims Act prohibits presenting false claims to government payers. The act was passed by Congress in 1853 and expanded in 2009 and 2010 with the Fraud Enforcement and Recovery Act and the Patient Protection and Affordable Care Act (Moseley III, 2013a). Under this law, organizations and individuals may not knowingly submit false or fraudulent claims to government bodies responsible for fulfilling them (ASHA, 2023).
Within the healthcare sector, these bodies are represented by such organizations as Medicare and Medicaid (ASHA, 2023). Prosecution may occur if it is proven that false claims were submitted with knowledge of being fraudulent or persons submitting them disregarding proper procedure (Moseley III, 2013a). The intent to defraud the government body, or lack thereof, does not come into consideration.
Policy Concerning the False Claims Act
Prevention, detection, and reporting of false claims being filed by the medical staff are among the hospital’s highest priorities. Failure to do so will result in fines being imposed on the facility or it being shut down if the fraudulent activity is regular and substantial (Moseley III, 2013b). Therefore, it is the legal responsibility of the hospital to foster a culture of honesty, transparency, and ethical behavior within the organization (DIY Committee Guide, 2022; Mayo Clinic, 2023).
All employees will undergo an onboarding program covering the hospital’s policies and procedures, coding standards, and documentation requirements relating to filing claims to different government agencies (Blue Beyond Consulting, 2021). Furthermore, regular training on filing procedures and standards will be offered to ensure the staff is familiar with new additions and introductions to billing requirements.
New detection procedures will be implemented to ensure that all hospital claims are legitimate. Specifically, new procedures for checking the legitimacy of the bills will be implemented, with hospital auditors examining the bills for compliance with the coding standards and protocols (Hook, 2023). Independent audits will be implemented to ensure validity and transparency. Additionally, staff suspected of filing false claims will have all their filings double-checked for compliance with the code and authenticity of the information provided.
Moreover, all employees are expected to report their suspicions of false claim activity in the hospital. As per this policy, all such reports are confidential to protect and prevent retaliation, regardless of the report’s outcome. The medical personnel responsible for filing false claims will be reported to the medical board, suspended, and required additional training. Numerous offenses will result in the firing of the involved staff members.
Conclusion
Overall, the policy aims to discourage false claims from being filed by hospital employees. All staff members are expected to report any witnessed or suspected fraudulent activity concerning filing medical bills. The hospital will implement additional audit procedures to ensure all bills are in line with the coding standards. The policy will ensure the facility operates with the culture of trust and sense of responsibility necessary to serve the community effectively.
References
ASHA. (2023). False Claims Act (FCA). American Speech-Language-Hearing Association. Web.
Blue Beyond Consulting. (2021). Building great culture in your healthcare organization. Web.
DIY Committee Guide. (2022). How to Develop Policies & Procedures Help Sheet. Web.
Hook, J. (2023). A medical billing audit can increase profitability. The Fox Group. Web.
Mayo Clinic. (2023). Code of Ethics and Conduct. Web.
Moseley III, G. B. (2013a). False Claims Act. In Managing legal compliance in the health care industry. Jones & Bartlett Publishers.
Moseley III, G. B. (2013b). Physician practices. In Managing legal compliance in the health care industry. Jones & Bartlett Publishers.
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