206009 False claims act and its application to healthcare quality

Monday, November 9, 2009

Angela Mattie, MPH, JD , School of Business, Management Department, Quinnipiac University, Hamden, CT
Andrea de Azevedo Miodonka, candidate JD/MBA , School of Business, Management Department, Quinnipiac University, Hamden, CT
The False Claims Act is emerging as the Federal government's most powerful tool to enforce healthcare quality standards. While the majority of False Claims Act (“FCA”) healthcare cases continue to revolve around the traditional fraudulent activities, such as billing for services not rendered, upcoding, violations of Anti-Kickback Statute and Physician Self-Referral (“Stark”) Regulations, there is a growing trend in use of the FCA to police substandard quality of care in healthcare institutions. Over the past decade, the government's use of the FCA in these cases has broadened the concept of “fraud” to include within its purview various quality of care violations as a new kind of fraudulent activity. The underlying argument in favor of the new breed of FCA claims is that the government, the largest buyer of health care, should not be paying for services that are so substandard as to be essentially useless. The birth of this new fraud is a result of the recent focus on quality of care as a major issue in the delivery of health care.

This presentation identifies the application of the False Claims Act (“FCA”) to substandard care cases in the healthcare setting. Discussed are the history and elements of the FCA, the legal theories the government has used to pursue substandard health care quality cases, and steps providers should institute to mitigate potential exposure under the FCA for allegations of substandard care.

Learning Objectives:
1. Describe the legal theories the government uses to pursue quality of care violations in healthcare settings 2. Formulate a plan to mitigate your organization’s potential exposure to a FCA violation as it relates to quality of care 3. Identify the elements of a FCA violation

Keywords: Quality Improvement, Federal Initiatives

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I have experience in graduate course design and teaching in this area, publications related to this area, and professional experience encompassing this area. Below are selected examples: TEACHING IN THIS AREA: LAWS310/HM 630: Health Care Compliance. I proposed, developed and teach this course to meet the industry need to formally train managers and attorneys in the field of healthcare compliance. This course serves as the foundation course for the health care compliance certificate and covers the management, legal, and auditing issues applicable to the health care compliance field. It includes the application of the FCA to quality. HM 621: Health Care Quality. I teach a graduate-level course on healthcare quality. HM 668: Legal Aspects of Health Care Delivery. I teach a graduate-level course on important legal issues facing healthcare managers. PUBLICATIONS IN THIS AREA: Accepted for Publication. (Anticipated Publication Date: Summer 2009). “The Federal False Claims Act and Qui Tam Actions: What Every Healthcare Manager Should Know.” Journal of Legal, Ethical and Regulatory Issues, Mattie, Angela; Ben-Chitrit, Rosalyn. (Oct-Dec. 2008). Centers for Medicare and Medicaid Services’ “Never Events”: An Analysis and Recommendations to Hospitals. The Health Care Manager. (Volume 27, Number 4, pp. 338-349). Mattie, Angela; Webster, Barry. (November 2007). “Patient Safety Legislation: A Look at Health Policy Development and Implications for Nursing Practice.” Policy, Politics and Nursing Practice. (Volume. 8, Number 4, 251-261) . Mattie, Angela; Ben-Chitrit, Rosalyn. PROFESSIONAL EXPERIENCE IN THIS AREA: 2001 to 2003 Sisters of Providence Health System; Springfield, Massachusetts Vice-President, Performance Improvement • Oversaw legal, quality, risk management, worker’s compensation, infection control, HIPAA privacy implementation, and corporate compliance for health system; • Minimized risk to the health system by developing and implementing a corporate Compliance program while acting as Corporate Compliance Officer; September 2000 to October 2001 Office of Senator Jeffords; U.S. Senate Health, Education, Labor & Pensions Committee; Washington, D.C. Robert Wood Johnson (RWJ) Health Policy Fellow • Selected as one of six RWJ Fellows; • Served on Senate Committee staff responsible for major healthcare issues;. July 1997 to October 2001 (Organization Nominated Fellowship 8/2000-10/2001) Anthem Blue Cross & Blue Shield; North Haven, Connecticut Corporate Medical Policy Office • Minimized legal exposure by designing strategies and implementing processes for uniform medical policy across corporation; • 1989 to July 1997 The Connecticut Hospital Association; Wallingford, Connecticut Assistant Vice-President, Quality Improvement Services, 1993 to July 1997 Director, Quality Improvement Services, 1992 to 1993 Coordinator, Quality Improvement Services, 1989 to 1992 • Oversaw statewide clinical outcome program producing reports for improvement in patient care; EDUCATION J.D., Admitted to the Connecticut and Massachusetts Bar. University of Connecticut School of Law; West Hartford, Connecticut ; M.P.H., Yale University School of Medicine, Department of Epidemiology and Public Health; New Haven, Connecticut; B.S., Summa Cum Laude. Quinnipiac University; Hamden, Connecticut. ACADEMIC EXPERIENCE: August 2003 to Present Assistant Professor of Management, Quinnipiac University, School of Business; Department of Management, Hamden, Connecticut School of Business.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.

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