Essay Sample on U.S. Healthcare Fraud: Putting Profits Ahead of Patient Care

Cases of fraud in the United States continue to affected delivery of quality healthcare; several healthcare practitioners and healthcare organizations have been faced with different allegations involving fraud (Flasher & Lamboy-Ruiz, 2019). Most of these cases are linked to financial gains and the quality of healthcare service delivery. Individuals and organizations involved consider putting profits ahead of patient care, legal and ethical requirements (Rao, 2020). In many cases, unnecessary tests and irrelevant administrations of medicines are identified as the main problems and allegations facing these individuals and health care organizations. Government and investigation agencies have reported many cases of fraud in healthcare and establish legal consequences for those found quality of fraud (Jesilow & Burton, 2017). It is crucial for healthcare providers and organizations to realize the legal impacts of conducting fraud and work to improve their quality of care in compliance with the organizations and federal law. The government has provided clear guidelines to control the healthcare service and eradicate the case of fraud as an intervention to protect its citizens from unlawful and unethical practices. This paper, therefore, provides an overview of the fraud case involving Ebenezer Quainoo, an internist in Baltimore Healthcare, Maryland.

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Ebenezer Quainoo agreed to pay $436,000 to the government following allegations of false claims act (United States Department of Justice, 2020). The doctor submitted false claims to justify his unlawful and unethical act. The doctor practiced unnecessary autonomic nervous function tests on patients and carried out point injection by ultrasound guidance. In his practice, Ebenezer without following proper medical requirements to justify the need for the service. The test is a relatively unusual disorder. Besides, diseases that require such tests must be done only after the doctor suspects that the patient is suffering from an autonomic nervous function disorder (United States Department of Justice, 2020). The test can only be carried out once for each beneficiary provided that the facility or the practitioner has all the necessary equipment. He or she must be specialized and trained to administer the test and medication. Therefore, based on the case, the doctor was not compliant with the documentation from conducting the tests that were not necessary.

On the other hand, trigger point injection is usually used to treat patients who have localized muscle pain; this is conducted only in places where there are painful knots or palpable nodes. However, this happens only after the non-invasive medical services like topical, relaxers, physical therapy, and analgesics have been proven unsuccessful. The doctor failed to provide consistent claims to support the practice because he did this for fraud (United States Department of Justice, 2020). He was not compliant with the law and medical documentation; therefore, he was charged for medically providing unnecessary tests and irrelevant injections using ultrasound guidance.

In the U.S.A., fraud is taken as a federal crime with legal consequences including imprisonment of up to 10 years, in cases where fraud has led to severe damage on the victims the punishments can be more saver with heavy fines and imprisonment can be increased to 20 years (Stowell, Schmidt & Wadlinger, 2018). In this case, the doctor had to pay a fine of $436, 000 but it is vital to consider that the punishments can even be more severe; that is, the organization Baltimore Health Care can be suspended or closed. The patient did not have the disorder requiring the test, and he did not have the necessary equipment to perform the tests, besides it was unethical and unlawful. Besides, he did not have specialized skills; Ebenezer only utilized the test to monitor the symptoms of the patient without making any clinical decision. The case, therefore, provides a clear practice of fraud and the legal consequences.

Compliance with the law and medical requirements to carry out and tests or medical practice is essential for the doctors and the organization (Simpson, 2016). Other than avoiding legal consequences, a fraud-free medical facility can provide quality health services and gain and competitive advantage in the market. It would be necessary for Baltimore Health Care to ensure that all healthcare practitioners are well trained and have the equipment required to offer various tests and other medical services.

In a criminal context, a person or an organization found to have committed fraud can face high amounts of fines, sentenced to jail or probation, and the organization can be suspended from offering their services ad permanently closed depending on the nature of fraud committed. It is, therefore, critical for the organization to focus on competency-based healthcare services to avoid such cases and consider patient care more important than just getting profits. Besides fines and any other punishment that the government can impose on individuals or organizations fraud quilt of fraud, company's reputation is more important, to protect this the healthcare system must consider compliance as a critical factor. Poor reputation may lead to severe financial loss in the long run. Therefore the organization must advocate for a fraud-free work-environment to maintain a good reputation and financial state. Monetary damages for committing fraud in the U.S.A. are adverse, and individuals and organizations operating in healthcare should be concerned about all the activities taking place within their facilities (Gottschalk, 2016). Human resource management should be at the forefront of providing rules and guidelines to manage employees to avoid cases of fraud. In many cases, an individual or an organization like can be brought to criminal charges to face legal consequences.

The federal healthcare fraud provides clear guidance and consequence for healthcare systems and individuals found guilty of fraud. Healthcare systems that provide false claims to run a particular medical activity for the interest in earning more profits are highly considered fraudulent. They would face severe criminal charges Federal Bureau of Investigation and the Office of the Inspector General (I.O.G.) are tasked to investigate and bring to legal attention all cases of fraud in the healthcare system (Ogrosky & Shuren, 2020). An individual or an organization convicted of fraud can have serious financial consequences; they can be prosecuted for committing fraud under 18 U.S.A.C 1347 health care fraud (Stowell et al. 2020). Losing the licenses and right to practice in the industry are some of the most serve consequences of fraud that the practitioner and the organization should consider before committing such crimes because it can lead to adverse financial damage and influence the negative image of the healthcare organization.

A medical practitioner who lost the license for committing fraud may not have the privilege of getting back based on the severity of the act. Besides, they may be forced to incur restitution costs to continue serving in the healthcare system; this implies that they must return all the money they took illegally and face additional charges. Under federal law, healthcare practitioners are obligated to offer appropriate care and exercise in a manner that observes documented guidelines (Fabrikant et al., 2020). As alleged, the doctor charged of fraud for exercising unnecessary tests and injections the doctor may continue to face more consequences if the victims consider pressing charges following the damages caused by the infusion and wrong tests.

Conclusion

Conclusively, the case is important for healthcare practitioners and organizations to learn the impact of fraud and none-compliance. The company must consider promoting a fraud-free work environment and competency based-healthcare services to avoid legal charges. Fines and other financial implications of fraud are a saver, and the company should prevent such acts. Different sequences such as suspension, poor reputation, and consequences funds pose saver financial impacts to an individual and the organization.

References

Fabrikant, R., Kalb, P. E., Bucy, P. H., Hopson, M. D., & Stansel, J. C. (2020). Health care fraud: enforcement and compliance. Law Journal Press.

Flasher, R., & Lamboy-Ruiz, M. A. (2019). Impact of enforcement on healthcare billing fraud: Evidence from the U.S.A. Journal of Business Ethics, 1-13.

Gottschalk, P. (2016). Fraud examiners in white-collar crime investigations. In Research Handbook on Corporate Social Responsibility in Context. Edward Elgar Publishing.

Jesilow, P., & Burton, B. (2017). Detecting Healthcare Fraud and Abuse in the United States. In Oxford Research Encyclopedia of Criminology and Criminal Justice.

Ogrosky, K., & Shuren, A. (2020). D.O.J. and OIG Health Care Fraud Enforcement in 2020 and Beyond. Journal of Health Care Compliance—January–February 1.

Rao, P. R. (2020, June). Ethical considerations for healthcare organizations. In Seminars in Speech and Language (Vol. 41, No. 03, pp. 266-278). Thieme Medical Publishers.

Simpson, D. O. (2016). Healthcare programs and fighting healthcare fraud in the United States of America. U.S. Att'ys Bull., 64, 1.

Stowell, N. F., Pacini, C., Wadlinger, N., Crain, J. M., & Schmidt, M. (2020). Investigating Healthcare Fraud: Its Scope, Applicable Laws, and Regulations. William & Mary Business Law Review, 11(2), 479.

Stowell, N. F., Schmidt, M., & Wadlinger, N. (2018). Healthcare fraud under the microscope: Improving its prevention. Journal of Financial Crime.

United States Department of Justice (2020). Baltimore Doctor to Pay $436,000 to the United States to Resolve False Claims Act Allegations Relating to Medically Unnecessary Procedures.