The most difficult issue a hospital can face involves allegations of poor quality coupled with billing fraud. These allegations can be devastating to a hospital's operations and its reputation. It is essential that hospital administration, the medical staff, legal and compliance officers work together quickly and efficiently to verify and address allegations. Hospitals should have at least an informal plan in place to address allegations. This prevents misunderstandings and potential duplication of roles that can result in further allegations that the hospital or medical staff isn't addressing the potential issue as happened in the notorious "Redding" case.
The informal plan should address the questions like whether
there will be a dual medical staff and compliance
investigations. There may be situations where a dual
investigation is warranted or where only one investigation is
necessary. For example, if the allegations primarily involve
patient harm, the medical staff might step in first and investigate
whether a suspension is warranted. Provided the medical staff
is doing its best to timely address the patient harm or even
patient care issues, there might not be a reason for compliance or
legal to get involved. In other situations, the medical staff
might decline to investigate a pure reimbursement issue which
compliance might investigate with the prior understanding to notify
the medical staff of any patient care issues.
Sometimes it's is helpful to bring in outside counsel to start
the discussion between the parties and outline the risks of not
having a plan in place. Either way, thinking and planning for
these type of allegations is worthwhile and will save time, money
and potentially reputation costs down the road.
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