Criminal Behavior by Healthcare Providers or Organizations

The United States federal government has created numerous programs to combat fraud and abuse in the healthcare industry. The government now encourages healthcare facilities to have a corporate compliance program, a plan that reduces the chances that the facility will violate laws or regulations. A corporate compliance program is an organization-wide program comprising a code of conduct and written policies, internal monitoring and auditing standards, employee training, feedback mechanisms, and other features, all designed to prevent and detect violations of governmental laws, regulations, and policies. It is a system or method ensuring that employees understand and comply with laws that apply to what they do every day. The way a corporate compliance program is promoted within an organization can profoundly influence organizational culture.

• Conduct an online search to find a legal case, journal article, or detailed news article that describes a recent criminal case involving the kind of healthcare facility in which you are interested in working. The case you select should focus on fraud or abuse (such as defrauding the Medicare or Medicaid programs, the Stark self-referral law, anti-kickback statute, or price-fixing) or other criminal act, such as patient abuse, murder, or theft. Evaluate the laws that are involved in your case and consider the ramifications of this criminal or civil action on the individuals and organizations involved.
• A good source for cases is the Medicaid Fraud Control Unit. Consider looking through one or two state websites, which can be accessed at the About the Medicaid Fraud Control UnitsLinks to an external site. webpage and search for the area that provides more information about and links to each state's Medicaid Fraud Control Unit.
• As you analyze your case and prepare for the Discussion, consider possible motivations behind this criminal act. What could an administrator do to prevent this from happening or to address it effectively once it is detected? Would a compliance program (refer to "Compliance 101" in the Learning Resources) be of value in preventing or detecting and then correcting this criminal issue?
• Briefly describe the case you selected and briefly describe the state and/or federal laws that are involved in your case. (If you are an international student, briefly describe the regional laws that are involved in your case.)
• Explain the ramifications of this criminal action or other action for the individuals and organizations involved (e.g., states working with the federal government in capturing fraud). Specifically, identify the penalties that resulted for individuals and organizations.
• Analyze the possible motivations behind the criminal act committed in the case you selected and how it relates to health care.
• Describe at least two basic ethical principles that may apply to this case.
• Finally, identify actions healthcare leaders can take to mitigate or prevent this type of issue.

Support your response by identifying and explaining key points and/or examples presented in the Learning Resources.