Question

One key objective of the compliance plan in a healthcare organization is to create a secure and effective reporting process, thereby avoiding qui tam lawsuits against the facility. What is a qui tam lawsuit, and how can we avoid them? Can you envision any situation in which you yourself might file a qui tam lawsuit?

Answer 1

A qui tam lawsuit is the one which is filed by an individual whistleblower(whistleblower is anyone who reports illegal activities that take place in an organization) as part of the False Claims Act (FCA), a law that was introduced for the punishment of people or organizations who file false claims for funds from government programs.

The False Claims Act enables the government to recover losses from private entities that overcharge the government for services.Here,the whistleblower alerts the government of potential fraud or overcharges, which prompts an investigation.The government then brings a qui tam lawsuit to recover the funds if the investigation is found to be successful.This type of lawsuit is common in the healthcare industry.

WAYS TO AVOID A QUI TAM LAWSUIT

1)By the institution of complete policies

Institute company-wide policies is the first step to avoid a qui tam lawsuit.This can be done by consultation with an attorney to implement policies, compliance plans, and procedures that are required by federal and state law. The prime focus of these policies will be on fraud, abuse, and on providing optimal patient care.

2)Regular training of staff

This is done to remind them of what is required by them under the law and current policies. Ideally, staff should be trained every few months, or as necessary when laws change. Training should be based on aspects like billing practices, patient care etc.

3)Careful inspection of each contract

This should be done to ensure that contract complies with both federal and local regulations.Hence being alert and thorough when creating and reviewing contracts can be effective in avoiding quitam lawsuits.

4) Implementation of an internal whistleblowing program

This can be done by encouraging staff and management to cooperate on reporting improper conduct or problems. Creating an environment that makes the staff feel safe to come forward helps in catching issues and correcting them before they develop.

5)Creation of internal monitoring programs

This ensures that all policies and regulations are being complied with. Anual audits should also be considered in this regard.

• I can file a qui tam lawsuit for a Medicare fraud,that is, if billing is done for services that were not provided. For eg,if the nursing home where I am employed failed to provide the appropriate tests, scans, medicine, staff members, doctor visits or supplies for a patient,but still bills it for maximising the reimbursement,the this is an obvious Medicare fraud that I can report.