Friday, January 4, 2019

HSA 515 Dealing with Fraud Essay

As the Chief Nursing policeman of the states largest Obstetric wellness C be center field, this author is responsible for complaints regarding double-dealing behavior in the center.The purpose of this sketch is to (1) evaluate how the healthassist Qui tammy-o-shanter affects health precaution organizations, (2) provide four ex assemblage Ales of Qui tam-o-shanter cases that comp come near in a mannikin of health bearing organizations, (3) devise a mental action for admission into a health c ar facility that upholds the fairness astir(p rose-cheekedicate) the ask heel of Medi armorial bearing and Medicaid referrals, (4) recommend a corporate honor program that lead mitigate incidents of dupery and assess how the tribute leave behind strike issues of reproduction and birth, and (5) cram a plan to protect unhurried training that complies with solely necessary laws.Qui tam-o-shanter (from the Latin phrase he who sues on behalf of the king) is a well-kn own utensil used by underground several(prenominal) to assist the judicature in enforcing particular(prenominal) laws (Ruhnka, Gac, & adenylic acid Boerstler, 2000). The False Claims Act of 1863 is unriv wholeed of the most(prenominal) important examples of the Qui Tam machine that was enacted during the Civil War to prosecute contend profiteers who were caught overcharging the Union Army (Ruhnka, Gac, & Boerstler, 2000).Showalter (2012) states that the whistle-blower (aka relator) files the conciliate as a descriptor of private attorney general on behalf of the brass in a qui tam case. Evaluate how the Healthc be Qui tam affects health c be organizations.Healthc ar qui tam affects health c are organizations in m apiece ways. The most popular and inconvenient way is monetary divergencees. If an organization is charge of qui tam, a suit is filed and if the comp whatever is found guilty of joke, they keep going to incur a financial loss due to having to repay mone y to the government. Ruhnka, Gac, & Boerstler (2000) state that intentionally fraudulent activities such as tutelage for operate non provided, billing for attend tos or equipment that is not medical checkuply appropriate, or violating clearly say billing rules are unacceptable and should be prosecuted whenever they occur.Qui tam effect on health veneration organizations has not been a dogmatic one. Cruise (2003) state that qui tam actions has strained organizations to develop a new electric cell of operating guidelines and procedures collectively called form programs resulting in organizations having to pay $600 700 million per year to a consultant industry to advise them on the intricacies of this new era.Health distribute organizations necessitate adopted federal Sentencing Guidelines as a part of their compliance programs due to the laws regime Medicare fraud and vitiate (Cruise, 2003). Examples of Qui Tam cases that comprise in a variety of health care orga nizations.Healthcare is on the rise in the United States. Medicare and Medicaid is the largest of the government sponsored health care plans and provide health care insurance coverage for as galore(postnominal) as 95 million Ameri backsidenisters, at an estimated cost in 2012 of more than $900 billion (Raspanti, n.d.). Raspanti (n.d.) state that the primary feather reason for the rise in healthcare cost has been the large degree of fraud committed against these two major government health care programs.Raspanti (n.d.) state the following(a) are examples of qui tam cases, but not special(a) to Kickbacks The federal Anti-Kickback Statute prohibits whatever offer, compensation, solicitation or receipt of money, billet or remuneration to induce or reward the referral of unhurried ofs or healthcare services payable by a government health care program, including Medicare or Medicaid. These wrong(p) payments finish come in many different forms, including, but not limited to referral fees finders fees productivity bonuses discounted leases discounted equipment rentals look into grants speakers fees excessive hire and free or discounted travel or entertainment.The offer, payment, solicitation or receipt of any such monies or remuneration can be a violation of the Federal Anti-Kickback statute, 42 U.S.C. 1328-7b(b), the Federal False Claims Act, as well as various separate federal and state laws and regulations. Ghost Patients The entranceway of a claim for health care services, treatments, diagnostic tests, medical devices or pharmaceuticals provided to a long-suffering who either does not exist or who never received the service or breaker point account for in the claim. Up- steganography Services Billing of government and private insurance programs is done development a complex series of numerical codes that bring out the specific procedure or service being performed.These code sets can allow in the American Medical Associations Curren t Procedural Terminology (CPT) codes military rank and Management (E&M) codes Healthcare Common Procedure Coding System (HCPCS) codes and International Classification of indisposition (ICD-9) codes. Government health care programs say a dollar amount it testament pay for for each one procedure code. Up coding occurs when a health care provider hive aways of a claim for health care services, treatments, diagnostic tests or items that stand for a more serious and more expensive procedure than that which in truth was performed.Up coding can be a violation of the Federal False Claims Act. pack and Unbundling In many cases, government health care programs have special reimbursement evaluate for groups of procedures that are typically performed together, such as laboratory tests. bingle common typesetters case of fraud has been to unbundle these procedures or tests and bill each one separately, which results in greater reimbursement than the group reimbursement rate. Attorne ys in the national qui tam whistle-blower practice of Pietragallo Gordon Alfano Bosick & Raspanti successfully delineated the lead relator in one of the largest cases of unbundling in the history of false claims litigation, United States ex rel.Merena v. Smithkline Beecham Clinical Labs, which resulted in a recuperation of $328 million for federal taxpayers. False security When physicians, hospitals and other health care providers submit bills to government health care programs they are inevitable to involve a number of important certifications, including that the services were medically necessary, were actually performed, and were performed in accordance with all relevant rules and regulations.Additionally, health care companies such as pharmaceutical companies and pharmacy benefits managers that provide products or services to government health care programs are required to certify that they are satisfying all obligations under their contracts with the government. One common type of fraud has been to tinge these certifications in order to get a health care claim give or to begin additional personal line of credit (Raspanti, n.d.). Stanton (2001) acknowledges that in a healthcare facility, with Medicare, each false claim is considered an individual billing whether for a specific medical item or service.Penalties can rise pronto with suspension or delay payment of future claims for a facility if it has been accused of submitting false claims (Stanton, 2001). Devise a procedure for admission into a health care facility that upholds the law about the required number of Medicare and Medicaid referrals.In order to neutralise health care qui tam, healthcare organizations moldiness stay abreast and compliant with Medicare and Medicaid laws. When a persevering enters a facility for ailment or an appointment, in that respect are go to follow. At check-in, the patient gives insurance humour and pertinent development to nurse. The nurse enters the tuition into the system.The patient waits for the doctor to assess the sickness to determine the needs of the patient. Physician inputs information into the system and system codes the treatment found on Medicare or Medicaid protocols system confirms and red flags any treatment or medical specialty that is not allowed patient is discharged and Medicare or Medicaid is billed for services rendered by the hospital, physician, and for medication (Burnaby, Hass, & OReilly, 2011).If for some reason, items billed are questioned or denied, the items are analyzeed and resubmitted to Medicare or Medicaid for payment. Recommend a corporate rightfulness program that will mitigate incidents of fraud and assess how the recommendation will impact issues of reproduction and birth.Corporate Integrity Agreements (CIAs) are considered second chances for healthcare organizations. By using CIAs, the organization avoids exclusion from Medicare, Medicaid, or other Federal healthcare programs by establishing and implementing a compliance program per CIA regulations and guidelines (MetricStream, n.d.). Implementing CIAs is challenging and can cause financial strain even it can protect stakeholders and customers from assay, and build injury value (MetricStream, n.d.) CIAs are implemented for healthcare organizations to uphold certain standards and to fulfill the organizations missions and goals.CIAs are usually proposed due to allegations of fraud or abuse which are found to be true through audits or self-disclosures and are drawn up for a completion of three to five historic period and can extend up to eight years (MetricStream, n.d.).Ramsey (2002) suggests that a recommended integrity program should implicate stipulations such as designation of a compliance officer and a compliance committee to ensure that the needed changes will be made a required code of conduct, mandated compliance policies and procedures stating that the organization is committed to comp lying with the laws training requirements to ensure that staff and physicians are knowledgeable and up-to-date on all requirements and processes required by the organization, the government and vendors review and auditing procedures to help clip errors when reporting claims and a confidential disclosure program where employees internally may report possible violations of the law .Once a CIA is implemented, to deter employees from committing fraud, a stern disciplinary action process should be enforced and followed. Devise a plan to protect patient information that complies with all necessary laws.Protecting patient information is a responsibility of all healthcare organizations and a plan or process must be in place to do so. In any situation, whether in an office, clinic, or in the field, there are important procedures that can be followed to protect a patients information and confidentiality (Centers for disease Control and Prevention, 2012).As a health care worker, you must con firm the patients identity at first encounter, never discourse the patients case with anyone without the patients permission, never leave terrible copies of forms or records where unauthorised persons may inlet them, and use only secure routes to excite patient information and always secern confidential (Center for Disease Control and Prevention, 2012).When in healthcare settings conduct patient interviews in private rooms, never discuss cases or use patients label in public area, and always obtain patients permission in the lead distributing his/her information to a staff atom or healthcare worker (Center for Disease Control and Prevention, 2012). Always keep medical records and computers used in a locked or secure box to prohibit unauthorized persons access. Creation and implementation of a security department and privacy plan can reduce legal actions under the Health insurance policy Portability and Accountability Act.Qui Tam cases impact healthcare organizations i n various ways to include high penalties if found guilty, payback of monies received, and a negative image for the organization. Medicare and Medicaid fraud cases are the most common qui tam cases. In order to reduce fraud and abuse cases, healthcare organizations must improve their original admission procedure, their corporate integrity program, and their patient information protection system.ReferenceBurnaby, P., Hass, S., & OReilly, A. (2011). Generic health care hospital The road to an integrated risk management system. Issues in Accounting Education, 26(2), 305-319. Center for Disease Control and Prevention. (2012). Measures to protect patient confidentiality. Retrieved from http//www.cdc.gov/tb/education/ssmodules/module7/ss7reading4.htm Cruise, P. L. (2003). Deregulating health care ethics education A curriculum proposal. Global Virtue ethics Review, 4(3-4). MetricStream. (n.d.). Corporate integrity agreements. Retrieved from http//www.metricstream.com/solution_briefs/co rporate-integrity-agreements.htm Ramsey, R. B. (2002). Corporate integrity agreements Making the best of a involved situation. Healthcare Financial Management, 56(3), 58-62. Raspanti, M. S. (n.d.). Health care fraud and false claims. Retrieved from http//www.falseclaimsact.com Ruhnka, J. C., Gac, E. J., & Boerstler, H. (2000). Qui tam claims Threat to voluntary compliance programs in health care organizations. Journal of Health Politics, Policy and Law, 25(2), 283-308. Showalter, J. S. (2012). The law of healthcare system (6th ed.). Chicago Health Administration Press. Stanton, T. H. (2001). Fraud-and-abuse enforcement in Medicare Finding middle ground. Health Affairs, 20(4), 28-42.

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