In this Whistleblower Case Cecilia Guardiola, a former employee of Renown Health filed a lawsuit under the False Claims Act against Renown Health on June 1, 2012. The plaintiff alleged that fraudulent Medicare claims have been submitted by Renown Health for short stay inpatient claims that should have been outpatient claims. The original complaint that was filed has been seal according to order at the request of the plaintiff (Health, 2014). According to information from case Guardiola was hired by Renown Health June 2009 as Director of Clinical Documentation with main responsibility to improve the medical documentation to support and enhanced billing. Guardiola was then promoted to a new position as Director of Clinical Compliance, she later resigned in January 2012 alleged that efforts to improve the billing system were precluded by Renown. (Guardiola v. Renown Health, 2014). …show more content…
In addition, Guardiola claims that the improperly billed claims were caused by “inadequate clinical documentation to support inpatient claims, internal processes designed to improperly assign inpatient admission status, antiquated computer systems that generated false claims, and a lack of review to ensure appropriate inpatient status assignments” (Guardiola v. Renown Health, 2014). It is noted that the plaintiff Guardiola discovered the alleged insufficiencies and claimed she brought it to the attention of management, but Renown takes no action to correct the problem and did nothing to prevent it from happening. The plaintiff claims that management at Renown directed, encouraged and facilitated the deceitful action to be continued against
While working at the OB-GYN department in the hospital, Dr. Vandall, as a Vice Chair of the Department of Obstetrics and Gynecology, learned that another employee of the hospital, Dr. Margaret Nordell was engaged in a level of treatment that was unethical and violated accepted standards of care. It was his duty to the hospital and to the patients, to monitor the competence of his staff members. Although he tried to take the proper steps to deal with it within the hospital, he ended up reporting this to the North Dakota Board of Medical Examiners. It was concluded by the Board that the treatment of Dr. Nordell was gross negligence and they suspended her license to practice medicine.
In the case of Tomcik v. Ohio Dep’t of Rehabilitation & Correction, the main issue present was the medical negligence demonstrated by the staff of the medical clinic at the Ohio Department of Rehabilitation and Correction towards the inmate Tomcik. Specifically, nonfeasance, or the “failure to act, when there is a duty to act as a reasonably prudent person would in similar circumstances” (Pozgar, 2016, p. 192), was displayed when the employees at the medical clinic failed to give immediate medical attention to Tomcik when she continually signed the clinic list and “provided the reason she was requesting
Showalter, J. S. (2012). The Law of Healthcare Administration (6th ed.). Chicago, IL: Health Administration Press.
In the summer of 2003, Gary Shephard learned that he needed to have surgery on his left knee. In accordance with the requirements of his insurance plan, Mr. Shephard obtained prior approval for the surgery from Blue Cross/Blue Shield and made plans to have the surgery on or about August 5, 2003. On August 1, 2003, a few days before his scheduled surgery, Mr. Shephard was laid off due to lack of work. (Shephard v. O'Quinn Case No. 3:05-CV-79, 2013) Defendant John O'Quinn, Gary Shephard’s boss, told him that the layoff would be temporary and that his insurance coverage was paid for one month after his layoff. Therefore, Mr. O'Quinn assured Mr. Shephard that his health insurance would still be effective the following week when he had knee surgery.
In the case of United States ex rel. Geraldine Petrowskivs. vs Epic System Corporation, Geraldine Petrowski worked as a the Supervisor of Physician’s Coding at WakeMed Health from 2008 until 2015. She was then trained to be a charge capture analyst for Epic’s billing charge capture system. After that she went on to work as a hospital liasion for the implemention of Epic at WakeMed Health. In 2015 Petrowski alleged that a glitch in Epic’s billing system had caused hundreds of millions of dollars in overbilling. Soon after, Petrowski filed a lawsuit with Florida’s U.S district. In the complaint Petrowski wrote “ Epic’s billing software defaults to charging for both the applicable base units for anesthesia provided on a procedure, as well as
One of the biggest contributors to health care costs that I have seen during my time in the healthcare industry is insurance fraud. One example of such fraud came about two months ago. I was taking a phone call from a provider that was upset that one of their claims had denied even though all of their previous claims had been paid. In researching with a partner plan it was determined that the claim denied because this medical provid...
"Tenet Healthcare Corporation, through its subsidiaries, owns and operates acute care hospitals and related health care services" (Tenet, 2007) "On September 27, 2006, Tenet Healthcare Corporation signed an annual update of its ongoing corporate integrity agreement (CIA) with the Office of Inspector General (OIG)" (Jones, 2007, p. 7). Tenet, as are many other healthcare organizations, is faced with “inadequate medical record documentation; poorly executed patient informed consent; inadequate patient education; poor physician-patient communication; lack of medical necessity for performed medical services; and improper performance of medical services” (Jones, 2007, p. 8).
However, there are certain issues that may result from unfilled gaps between the expected and the actual provided health care treatment, and these issues vary in severity. But unfortunately, there are many people as patients who may not be fully aware of their legal right to file clinical negligence claims that could have been valid and successful.
Medicare fraud occurs when healthcare providers, suppliers, and private companies charge for services or supplies patients never receive. Additionally, abuse of the Medicare program also occurs because physicians and suppliers do not always follow best medical practices which leads to excessive costs through improper payments, or medically unnecessary services, both of which abuse the program. Conservative estimates suggest he...
However, based on all these benefits and services that are provided, over the last decade they have been hit with numerous fines and citations that affect the organization as a whole (Agency for Health Care Administration, n.d.). Many of the public records complaints include: staffing issues, staff are incompetent, no care plans and inadequate care of the residents. Furthermore, the one major challenge that I faced at the
One important fact in this case is medication that the physician administered to the patient is not listed in the case study. All information must be documented, this helps to keep track in the event the patient gets a reaction this is significant information that must be recorded. Although this may be unimportant to the case this should still be listed. As this patient condition worsened he was diagnosed with osteomyelitis. As mentioned above knowing all medications being administered are important, when treatment first began the pharmacist in this case did exceptionally well keeping track of the medications being administered. Another important factor is that the pharmacist kept track of the care being provided to the patient because the pharmacist reviewed patient results he was able to make suggestions to the physician to check the patients creatinine levels. However the pharmacist in the case is the defendant. Although the pharmacist did well in reviewing the patient’s information during most of the treatment, he did fail to do a follow up check. The
Quality patient care is an ongoing endeavor that involves many different areas of healthcare. One area of healthcare that is often employed is Utilization Management. We read in John’s that UM “is composed of a set of processes used to determine the appropriateness of medical services provided during specific episodes of care” (John,2011). Things that are used to determine the appropriateness of care include the patient’s diagnosis, site of care, length of stay, and other clinical factors. This system consists of three main functions aimed at improving patient care and controlling healthcare costs. These functions include utilization review, case management, and discharge planning. One source states that it also includes the claim denials and appeals process (Interviewee C. Jarvis, e-mail communication, May 3, 2014). When used correctly, these UM processes can expedite the patient’s care and reimbursement. It also demonstrates to third party payers that the organization is taking measures to help control costs. This monitoring and management of patient healthcare needs ensur...
At times case managers are faced with decisions of balancing the needs of their employers, for example doing what is financially best for them, or directly doing what is best for the patient. In this case, when case managers communicate to patients that, insurance companies are denying treatments, surgical procedures doesn’t require inpatient stay, post discharge services such as homecare, or transfer to acute rehab facilities, case managers are taking the side of the organization and not the patient’s
This article includes recently released information about an incident that has been completely settled. The article states that a nurse practitioner, Martha C. Smith-Lightfoot, took a spreadsheet from University of Rochester Medical Center (URMC) that contained around the information of around 3,000 patients. She had previously worked at URMC, but she had switched jobs to work at Greater Rochester Neurology. When she left URMC, she took the spreadsheet with her without their URMC’s consent.
Anyone who discovers questionable Medicare and Medicaid fraudulent practices can file a confidential legal claim under the False Claims Act. –Author