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…
Based on information from the case document no 87, Guardiola claims that Renown Health meaningfully submitted or “reckless disregard of the truth” allowed claims to be submitted to Medicare for short stay (zero-day stay) inpatient claim instead of outpatient claims.
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
Medicare. The defendant Renown Health filed a motion to dismiss the case that was denied, in addition several other complaint and motion have been filed on the case some of which have been granted and others denied. June 2016 Renown Health paid the Department of Justice $5.9 million to resolve the alleged lawsuit (Nevada U.S. Attorney's Office, 2016). The case is still opened as the plaintiff file a suit claiming that the United States originally “declined to intervene in the action then decided to pursue the same claim against Renown through a process called a Recovery.” (Guardiola v. Renown Health, 2016) Guardiola is requesting that the court order the United States pay her relator’s share of 29 percent of the funds recovered from Renown Health from the False Claim Act. In the court documents, it is noted that the United States filed an opposition instead of responding to the plaintiff claims that Guardiola should be barred. After several court appearance on October 23, 2017, Judge Larry R. Hicks from the Ninth Circuit of Appeal ordered that Guardiola motion is granted for relief from the final judgment. Since then the case has been changed to read Cecilia Guardiola, plaintiff, v. United States of America, Defendant. (Guardiola v. Renown Health, 2017). Since the Nevada U.S. Attorney's Office Collects $5.9 million monetary awards for Cecilia Guardiola based on twenty-nine percent would be approximately $1.7. I believe this situation could have been prevented and stayed out of the court if Renown Health would have acted to correct the problem and prevent it from continued to happen. Also, the case could have been closed if the Department of Justice District of Nevada had decided to intervene instead of filing their own case to cut Guardiola out of her reward.
FACTS: Dr. Robert Lee Berry (Defendant) was a practicing anesthesiologist, who practiced with Dr William Preau and Dr. Mark Dennis. He was also shareholder in Lakeview Anesthesia Associates, LAA (defendant). Berry also had staff privileges at Lakeview Medical Center (LMC) (Defendant). In Nov 2000, Lakeview (Defendant) investigated Dr. Robert Berry after nurses concern. In March 2001, Berry was found groggy, unfit to work and sleeping in a chair, Based on this incident and suspicions that Barry was stealing Demerol from the hospital, he was terminated from LAA and Lakeview and his LMC staff privileges were withdrawn. Afterward, Berry applied for job as anaestheologist in Kadlec Medical Center (plaintiff). Before employing Kadlec, the facility sent a letter to Lakeview requesting recommendations and included a questionnaire with specific questions to be answered.
Issue: The appellants are claiming that the court erred in determining that the Medical Liability and Insurance Improvement Act (MLIA) was not applicable in their claims. Mainly on errors and omissions of medical staff as well as asserted administrative negligence of the hospital that actually occurred before the defendant was admitted at the facility. The appellees’ motion relied on Rose v Garland County Hospital. (Las Colinas Medical Centre)
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.
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,’’.
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
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.
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...
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
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.
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
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...
"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).
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...
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