The topic of the present week of the course is devoted to the illegal issues that medical institutions face with their personnel. The materials given out in the present section are mainly devoted to giving a more detailed definition of fraud, waste, and abuse that are the main realizations of dishonesty from the part of employees, the ways to overcome them, and the legal basis for prosecution of these misdeeds. While defining fraud it is important to remember that it mainly constitutes different types of deliberate variations with financial assets of the hospital that include changing prices for medications or arranging inappropriate prescriptions to gain monetary profit from them in an illegal way. Waste in its core is the action of a bit different action as it may be both purposeful and non-purposeful, giving the medical institution financial losses. If waste is not based on the pursuit of profit, it is usually caused by the non-professionalism of the personnel who spoil or over-spend the materials, medications, or other resources of the medical institution because of their ignorance. In the case of intended waste, the evil intentions may be caused by some personal ways of using the resources of the hospital. More often it pertains to the usage of drugs that are intended for usage in smaller doses for some cases. Speaking about abuse it is necessary to keep in mind that it is a broader term that pertains to any non-ethical action from the side of a representative of a medical institution – not following the code of ethics, prescribing the wrong treatment, or committing any other illegal or wrong action (Preventing Fraud, Waste, and Abuse, 2009). In the course of activity of a medical institution, there is a set of measures presupposed for detecting such cases and legally punishing them.
It is important to understand why these procedures are of crucial importance in the medical care field. Medical care involves taking care of human lives – it pertains to illnesses and health problems of a different level of gravity and operations that affect human lives drastically. This is why the medical sphere workers must keep to the strict code of ethics and instructions of prescribing drugs, giving treatment to people, etc. This issue is too important and decisive for some people whose life is the object of doctors’ activity that no deviations from the norm or non-professionalism can be accepted in this respect. However, there have appeared some ways of financial illegal actions and violations of restrictions that affect the functioning of the present sphere and involve risk for human life as well as spoil the reputation of particular medical institutions.
The illegal actions, namely waste, fraud, and abuse are most commonly connected with the misuse of the funds allocated for financing the subsidiary programs such as Medicare and Medicaid in the USA, both from the side of doctors and patients. If one takes the issue from the side of patients, fraud usually takes place in the form of false claims and kickbacks (Preventing Fraud, Waste, and Abuse, 2009). This is the way patients may submit a claim for treatment in the case when they are not ill and gain material profit or get some drugs for sale in an illegal way.
To prevent these cases from taking place there is a set of measures worked out by the medical institutions’ administration that is called compliance processes. The main authority guiding these processes is the compliance officer or compliance committee (Preventing Fraud, Waste, and Abuse, 2009). Their main responsibility is to conduct continuous checking procedures to ensure the personnel’s compliance with the generally accepted norms of the code of medical ethics, with the obligations and responsibilities imposed on them by the hospital in which they work as well as with the norms of conducting treatment, personal communication with patients, etc. This is done to detect violations of any kind at an early stage and to eliminate them before they acquire a broader scale (Preventing Fraud, Waste, and Abuse, 2009).
One more way to reduce the cases of fraud, waste, and abuse in medical institutions is conducting continuous training of the personnel to achieve a set of preventive and educational measures. The first aim is to achieve a comprehensive understanding of the concepts of fraud, waste, and abuse by the members of the medical personnel to explain that these actions are illegal and punishable by law. This aim is guided by the consideration of the fact that some people may commit unlawful actions because they do not realize the full scope of consequences and sometimes even do not understand the gravity of their misdeed. Knowledge about all possible penalties awaiting them upon detection of fraud, waste, or abuse is likely to reduce the wish of the person to commit such misdeeds and to improve the level of their compliance with the standards established by the medical institution.
Another aim to be achieved is the initiation of cooperation of the employees with the administration in the sphere of detection of cases of fraud, waste, and abuse by some members of the personnel. This aim is achieved through detailed explanations of the rights of the person reporting about the misdeed thus breaking the usual perception of the report as an unethical, wrong action. All rights and responsibilities of people who have detected the case of fraud, waste, or abuse and want to report about it are given out to enhance people’s understanding of the fact that they are beyond the risk of remaining a traitor in the eyes of the rest of the personnel. It is surely a very vague ethical issue – to report or not to report – as the majority of people will keep to the position of silent permission at the stake of their reputation of reliable friends and colleagues. However, intense work is being undertaken nowadays to ensure people’s understanding of the ways they may report about misdeeds and remain ethically correct, which increases the cases of the personnel’s cooperation with the compliance officers (Preventing Fraud, Waste, and Abuse, 2009).
What is even more important in the aspect of personnel training on fraud, waste, and abuse is the need to define the most vulnerable groups of personnel who are most likely to commit these actions because of their increased access to the hospital’s resources. These groups include those who work with filing, dispensing drugs, financial accounts as well as sales and marketing of medical services and products (Preventing Fraud, Waste, and Abuse, 2009).
Coming to the final stage of discussing fraud, waste, and abuse in medical institutions it is necessary to enumerate the range of possible penalties presupposed for these violations. They may be on the federal scale including heavy financial penalties, exclusion from participating in Medicaid and Medicare, criminal prosecutions. Other measures of punishment may include investigations, outside auditing, and monitoring, law enforcement actions, etc. (Preventing Fraud, Waste, and Abuse, 2009).
In general, despite all actions taken by the compliance committees and officers, joint actions of the administration with the staff of medical institutions cases of fraud, waste, and abuse are still regularly detected in this field. Thus, it is important to keep in mind that any contribution of the personnel in the detection process as well as an increased understanding of the gravity of these offenses may become a better basis for improving the situation in the field.
Bibliography
Week 3 Fraud Simulation (2009). University of Phoenix, 41.