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
In the case of Michael T. Vandall, M.D., Plaintiff and Appellant v. Trinity Hospitals, a corporation, and Margaret C. Nordell, M.D., the issue is about retaliatory discharge. It deals with problems with Trinity Hospital in North Dakota, Dr. Margaret Nordell and Dr. Michael Vandall, both physicians working in the OB-GYN department.
Pozgar, G.D. (2012). Legal Aspects of Health Care Administration. United States of America: Jones and Bartlett Learning, LLC.
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
Learning from what Dr. Anna Pou had to face with the lawsuits she was dealing with makes me cringe. As Healthcare professionals, having to worry of possibly being sued for believing what is right for the patient or as a whole for the hospitals health is ridiculous. Healthcare professionals like Dr. Pou, have taken the Hippocratic oath, and one of the promises made within that oath is “first, do no harm”. Often time’s society look at courts cases as a battle versus two oppositions, but Dr. Pou’s case it is not. In her statements from national television she states saying her role was to ‘‘help’’ patients ‘‘through their pain,’’.
“One of those obligations is that it must exercise a proper degree of care for its patients, and, to the extent that it fails in that care, it should be liable in damages as any other commercial firm would be
Showalter, J. S. (2012). The Law of Healthcare Administration (6th ed.). Chicago, IL: Health Administration Press.
Medical error occurs more than most people realize and when a doctor is found negligent the patient has the right to sue for compensation of their losses. Debates and issues arise when malpractice lawsuits are claimed. If a patient is filing for a medical malpractice case, the l...
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...
The major implication of this decision is that each state decides the type of evidence required to withhold or withdraw medical treatment from an incompetent patient. The state ...
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.
In the case Lunsford v. Board of Nurse Examiners, the nurse had an unprofessional conduct by violating a duty to her patient leaving the patient unattended and at risk of complications (BON, 2013a). Lunsford, as a professional nurse had the responsibility to assess the patient’s medical status and treat the patient within her scope of practice taking the appropriate measurements to prevent the worse, regardless of the doctor’s orders of sending the patient to another facility. “The Board of Nurse Examiners in Texas suspended the nurse’s license to practice after the Board found that the nurse’s conduct was unprofessional and dishonorable conduct likely to injure the public” (Wolf, 1986, p. 222). Nurse Lunsford fail to take the patient’s vital signs, and did not implement the nursing interventions required to stabilize the patient’s condition or to prevent complications. Her conduct is considered an “unprofessional conduct,” which is any act, practice, or administration that does not conform the accepted standards of nursing practice. Also, this case is a clear example of the nurse responsibility and accountability to act independently regardless of the physician’s order when this order is not safe for the patient. If the nurse has any objections about an order, the nurse has the obligation to question the physician. By no doing so, the nurse violates the nurse-patient relationship and put at risk the patient’s safety. In a situation, in which a physician’s order put the patient at risk, the nurse has the obligation to exert her professional judgement and withdraw from rendering services ordered by the physician (Wolf, 1986, p.
Healthcare services have been on the rise for over 10 years now. According to a 2012 consumer alert, the industry provided $2.26 trillion in payments for more than four billion health insurance benefit claims in the year 2011(Fraud in Health Care). The bulk of the claims and the mainstream of fraud and abuse stem from the Medicare system professionals, who are knowledgeable about the process and persuade new clients into handing over their pertinent information in hopes of deception and illegitimate claims. Multiple and double billing, fraudulent prescriptions, are some of the major flaws in this organization that has made the healthcare services industry curdle. (AGHAEGBUNA, 2011) This is a non-violet crime and is often committed by very educated people including business people, hospital, doctors, and administrators.
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...
In the United States, healthcare fraud and abuse are significant factor associated with increasing health care costs. It is estimated that federal government spends billions of dollars on the health care cost (Edwards & DeHaven, 2009). Despite the seriousness of fraud and abuse offenses, increasing numbers of healthcare providers are seeking new and more profitable ways to build business relationships. These relationships include hospital mergers, hospital-physician joint ventures, and different types of hospital-affiliated physician networks to cover the rising cost of health care (Showalter, 2007, p 111-114). When these types of arrangements are made, legal issues surrounding the relationship often raise. There are five important Federal fraud and abuse laws that apply to the relationship and to physicians are the False Claims Act (FCA), the Anti-Kickback Statute (AKS), the Physician Self-Referral Law (Stark law), the Exclusion Authorities, and the Civil Monetary Penalties Law (CMPL) and (Office of Inspector General (OIG), 2010). Out of five most important laws that apply to the relationship and the physicians, we are going to focus on the Anti-Kickback Statute (AKS) and the Physician Self-Referral Law (Stark law).