Many industries are reporting increasing numbers of whistle blowing incidents. The medical industry in particular faces increased risk of whistle blowing due to the extent of medical fraud and the facts that medical abuse victims are often targeted when they are particularly vulnerable and that medical fraud may result in serious harm and loss of life. Newbold and Sullivan (2008) report that medical fraud is on the increase and, “medical fraud or abuse approaches 10% of all health care expenditures, or roughly $100 billion dollars” (p. 21). Businesses and professionals within the medical industry must understand the laws governing medical fraud and abuse and the protections available to whistleblowers. In particular, the federal False Claims Act protections for whistleblowers are particularly strong and those wishing to expose fraudulent activity may do so under the umbrella of these extra protections.
Medical professionals are often reluctant to expose fraudulent activity. Applebaum, Grewal, Mousseau, and Molson (2006) reference research by Firth-Cozens in 2003,
The rationales doctors gave for not reporting were “that it would be impossible to prove, feared retribution, didn’t want to cause trouble, wouldn’t have been listend to, and no one would support me. The reasons nurses did not report “was fear of retribution, wouldn’t have been listened to, didn’t want to cause trouble, impossible to prove and no one would support me.” For those doctors and nurses who had not contemplated whistle blowing [hypothetical causes] were “that it would be impossible to prove, …not sure if they were right, and that they would be hurting a colleague.” (p. 8)
Fears of retaliation are not unfounded. Smith (2007) presents journalistic evidence of retribution against physicians that report “unsafe conditions or a colleague’s poor work in their hospitals” (p. 45). Smith proceeds to present results of a 1998 survey stating that 15% of emergency room physicians reporting substandard care were terminated (p. 45).
The primary legal instrument used by the Department of Justice for investigating medical fraud and abuse is the False Claims Act (FCA) (Newbold and Sullivan, p. 21). According to Newbold and Sullivan, “the False Claims Act covers virtually all forms of fraudulent behavior except tax fraud” (p. 22). Recognizing the challenges associated with protecting whistleblowers and the fact that serious frauds often require a whistleblower to be detected, the FCA includes special protections known as the qui tam provisions. “Qui tam is short for “qui tam pro domino rege quam pro se ipso in hac part sequitur”, which is Latin for “he who brings the action for the king as well as himself” (Newbold and Sullivan, p. 22). As Newbold and Sullivan explain, “When a private citizen files a qui tam case, it is submitted as a “sealed document” (that is, not to be seen by anyone but the claimant and the government) to the Department of Justice” (p. 22). By enabling private citizens to file suits on behalf of the federal government and with strong protections for claimant confidentiality, the government hopes to encourage participation in “its battle on fraud” (p. 21).
Schreiber and Marshall (2006) provide generic best practices for mitigating whistleblower risks across the following categories:
- Reporting complaints
- Conducting the investibation
- Protecting privacy
- Preventive measures
For medical businesses seeking to mitigate risks of fraud, abuse, and legal action being brought under the FCA, Schreiber and Marshall’s best practices may be combined with Newbold and Sullivan’s recommendations: training employees, having written policies and procedures, maintaining a disclosure program, and conducting internal compliance audits (p. 24). In addition, medical businesses must understand that the FCA’s qui tam provisions mean that the claim will be sealed and many of the details will be kept confidential. In situations like this, effective internal policies and controls will enable the business to respond to the claim; ineffective internal policies and controls will plunge he business into serious legal and regulatory difficulties.
Appelbaum, S. H., Grewal, K., & Mousseau, H. (2006). Whistleblowing: International implications and critical case incidents. Journal of American Academy of Business, Cambridge, 10(1), 7. Retrieved from http://proquest.umi.com.library.capella.edu/pqdweb?did=1061620821&Fmt=7&clientId=62763&RQT=309&VName=PQD
Newbold, J., & Sullivan, L. (2008). Odyssey healthcare: A department of justice investigation related to the false claims act. Journal of the International Academy for Case Studies, 14(7), 11. Retrieved from http://proquest.umi.com.library.capella.edu/pqdweb?did=1493109981&Fmt=7&clientId=62763&RQT=309&VName=PQD
Schreiber, M. E., & Marshall, D. R. (2006). Reducing the risk of WHISTLEBLOWER COMPLAINTS. Risk Management, 53(11), 42. Retrieved from http://proquest.umi.com.library.capella.edu/pqdweb?did=1164965031&Fmt=7&clientId=62763&RQT=309&VName=PQD
Smith, W. R. (2007). Pseudoevidence-based medicine: What it is, and what to do about it. Clinical Governance, 12(1), 42. Retrieved from http://proquest.umi.com.library.capella.edu/pqdweb?did=1198553061&Fmt=7&clientId=62763&RQT=309&VName=PQD