Essay on "Fraud and Abuse Case Healthcare"

Essay 8 pages (2218 words) Sources: 4

[EXCERPT] . . . .

In the case of fraud and abuse cases risk areas identified include; improper coding and billing, avoidance of improper inducements, encoding, unbundling.

When carrying out a baseline audit, risks areas are factored in especially when performing an internal review. The review can be self-audit meaning it can be performed by a facility billing and healthcare staff. This should be carried out periodically to bring into attention the follow-up of compliance programs. In case of problems portrayed by baseline audit or overpayment repayment is done and frequent monitoring is enhanced.

Written policies and procedures

This policies and procedures guide the staff and enable them to tackle with crisis. These standards include the risk areas identified. The responsibilities and expectations of employees are included in the code of conduct (Brosman & Roper, 2007).

It is recommended that a compliance resource manual be created that contains the facility written standards and procedure and relevant Medicare directive.

Developing action initiatives

In a situation where violation or an overpayment is discovered, it is the responsibility of compliance officer to conduct an investigation to determine the nature and extend of potential problem. Basing upon the issues discovered various corrective action plan undertaken for overpayments are made organized. The facility engages in corrective measures upon any staff members who were involved in violation. The corrective measures range from an educational meeting, sending the employee for training, termination suspension all the corrective actions should be thoroughly documented.

Use of well-publicized Guidelines

There are consequences resulting from acting in a noncompliant manner. Anyone who violates the facilities policies or standards is ready to face the disciplinary action (Brosman & Roper, 2007). The guidelines are well publicized for example it is well stated in training manuals. Disciplinary action can range from written warning and reprimand to suspension. For all disciplinary action documentation is done.

Appointment of a compliance officer

One of the staff members should be appointed to serve as compliance officer; his or her responsibilities are monitoring compliance activity and developing corrective action plans. This will aid in enabling reduce fraud and abuse cases (Canavan, 2006).

Training and education

This is one of the corrective action plans that will enable staff become familiar with the facilities risk areas, laws and procedures.

Laws addressing fraud and abuse

As a result of threat that healthcare fraud and abuse has brought to the economy. It has forced the Federal Government to pass legislation that address issues. Some of the laws addressing fraud and abuse are as follows:

False Claims Acts: this is enacted on those individuals who engage in supply of inferior products. Commonly used in Medicare and Medicaid context to protect the Government against charge of services not provided. Sign of prove is the submission of false claim.

Qui tam action: this is where a private plaintiff sues on behalf of the government. It protects relators/whistle blowers

Anti-kickback status: law that is against solicitation of remuneration, enacted against those who charge payment for referrals for services.

Physician self-referral probations: this is law that prohibits self-referral for a number of services. Healthcare practitioner is not allowed to refer a Medicare patient to a clinical laboratory in which a physician possesses financial interest.

Current development prosecution of health care fraud and abuse is through the Health Insurance and Portability and Accountability Act (HIPAA)concerned with civil money penalty law, resources utilization so as the federal government can overcome healthcare fraud. Through this law penalties for actions such as unbundling and encoding is realized (Brosman & Roper, 2007).

Conclusion

Massive response to the question of healthcare fraud and abuse has been realized through healthcare providers and organizations. This has led to development of compliance programs. Health information professionals owe to their employees, third-party payers, and the government at large assistance provision regarding prevention and submission of false or inaccurate claims.

References

Brosman, J., & Roper, J.M. (2007). The reality of political ethical conflicts: Nurse Manager Dilemmas. Journal of Nursing Administration, 27(9), 42-46.

Brodeur, D. (2008). Health care institutional ethics: Broader than clinical ethics. In J. Monagle & D.C. Thomasma (Eds.), Health care ethics: Critical issues for the 21st century (pp. 497-504). Gaithersburg, MD: Aspen. (Brodeur, 2008)

Bucaro, F. (May 24, 2008). Ethics gap provides dilemma for businesses. The Akron Beacon Journal, G11. (Bucaro, 2008)

Canavan, K. (2006, October). Nursing addresses troubling trends… READ MORE

How to Reference "Fraud and Abuse Case Healthcare" Essay in a Bibliography

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