Dealing with Fraud

Dealing with Fraud health C are Policy, Law, and ethics HSA 515 troop 09, 2013 Dealing with Fraud obstetric wellness dish out centers are a study(ip) source for providing care to millions of women around the country and a classify of medicine that involves pregnancy and child take. Studies of pathologic and physiologic functions of the female reproductive orbital cavity are also a diverge of obstetric care. Physicians in this domain commonly referred to as OB/GYNs and care for the m opposite and fetus during pregnancy. As party boss Nursing police forthicer of one of the demesnes largest Obstetric Health Facilities countless women are treated at this center.The module is richly a state of ware of the mission, vision, policies, and procedures that make a huge impact in the community. Women cuss on the care and attention received from the exceptional doctors on stave. Unfortunately, the eccentric person of care delivered and the service the infirmary is responsible for providing, word of fakerulent behaviors deplete been pass overed and mustiness be embraceed. As United States health care cost continues to rise, community depend upon privately funded health computer programmes and millions are alleviate uninsured due to funding by state and federal brass.The major presidency sponsored health care plans are Medicare and Medicaid political weapons platforms. Both programs make up a large portion of presidency spending. One key campaign for rising costs has been the enormous degree of bilgewater committed against government health care programs. Although billions take hold been exposed due to informants of qui tam-o-shanter, additional monies go along undetected. Ultimately, health care humbug used as a deceptive means to profit from health care agreements through the federal government and the reason the United States Government Accounting Office has categorized Medicare and Medicaid as high-risk programs. Various sources ev aluate the effect of qui tam in health care organizations and refer to the 1986 False Claim Act the effectiveness. The term whistleblowing recognized by provisions in the False Claims Act and authorizes cases be brought to the government on behalf of the United States to share in the recovery efforts. The Informers Act or better known as The Qui Tam Statue is from the Latin phrase qui tam pro domino rege quam pro seipse, meaning he who as much for the king as for himself, established during the civil war and focused on ending dishonest suppliers to the union military.Therefore, fraud investigation, and legitimate action became easier for the government. The history behind qui tam statue and todays use provides an on a lower floorstanding to the term whistleblower and for an individual with past or personate knowledge of fraud on the federal government to recover restoration and impose penalties, (Cruise, n. d. ). Fraudulent behavior or health care fraud cloaks health care orga nizations. Several demeanors businesses and individuals have defrauded, and continue to defraud, federal, and state government health care programs.Examples of unsound behavior include No Services Non-submission of claims for diagnostic tests, handlings, devices, or pharmaceuticals serve that were never rendered. Non Existence Involves submitting a claim for the services previously mentioned and provided to unhurrieds that do not exist or never received service. Also an item billed for in the claim. Anti-Kickback jurisprudence bans any offer, payment, solicitation or communicate of money, property or payment to persuade or reward enduring referrals or health care services funded by a government health care program, including Medicare or Medicaid.These are unlawful payments and come in several different forms, includes barely not limited to referral fees, finders fees, productivity bonuses, research grants, inordinate compensation, and free or discounted travel or enter tainment. The offer, payment, solicitation or receipt of any such monies or remuneration can be a violation of the Federal Anti-Kickback statute, 42 USC 1328-7b(b), the Federal False Claims Act, various other federal, state laws, and regulations, (Pietragallo, Gordon, Alfano, Bosick, and Raspanti, LLC, 2013).These are just a small number of fallacious activities currently affecting health care organizations. Qui tam has been an effective describe in combating fraud. The Justice Department continues to recover record amount of judgments and settlements, that, qui tam cases exist in a variety of health care organizations. bear on and payment errors of Medicaid and Medicare patients whitethorn appear to be simple mistakes and not by medical exam professionals attempting to take advantage of the organization, but individuals intent on abusing the system particularly, with working nowledge of how and when the government pays Medicare and Medicaid claims. Also in some cases fraud aff ects the people with these programs and liability occurs for co-payments and contributes to excessive government spending. Other examples of qui tam cases include spoilt pricing/false negotiation reflects price adjustments by submitting false data and pricing to the government to receive an inflated amount according to the commence price. Mischarging one of the more widespread frauds used to submit claims for products or services never provided or rendered.Product/service substitution A product is bear witness that does not meet specifications or submitting a product for government compliment then substituting the merchandise with another of poorer quality. False certification advantage entitlement documents are falsely certified. Information submitted to the government has been adjusted for price supports or mortgage guarantees, according to the source more than half of qui tam recoveries have problematic health care fraud, qui tam lawsuits filed have been successful aga inst defense force contractors and other companies, (Einstein Law, 2008).Various federal and state requirements must be conform to by the health facility prior to admission. For example, pre-admission evaluations for Medicaid patients require prior tendency for eligibility. A full patient assessment will determine a plan of care. The prescribed care plan is prepared by the attention physician and registered nurse. Other hospital round will get involved with the patients care if essential. The care plan is updated on a quarterly arse, or more frequently if the patients terminal figure changes.Other requirements for Medicare and Medicaid patients must be met before admission to determine suitable purlieu and to respect patients rights after admission while receiving medical care. Procedures for admission into a health facility for Medicare and Medicaid referrals must understand and keep up with the laws that govern these procedures. The Anti-Kickback Statute (AKS) enacted by Congress delivers criminal penalties for the payment of fees knowing to persuade or reward medical referrals for discourse covered by Medicare and Medicaid.The AKS is extensive and includes discounts for physician referrals. Liability is a major concern under the Anti-Kickback Statue unless procedures fall within the law. Another regulation that limits physician self-referrals for Medicare and Medicaid patients is The Stark Law. Hospitals or health care providers are prohibited from receiving payments or kickbacks after improper billing Medicare for selected equipment or services. Ultimately, claims cannot be submitted by physicians for items or services because of their monetary relationship with the health care providers.The Stark Law passed because of inappropriate financial relationships between doctors and health care providers and the professional judgment of doctors with regard to whether items or services are medically necessary, safe, or effective also turn off probab le overpayments by Medicare for uncertain services, (The Qui Tam Team, 2012). The next stage is for physicians and nurses palingenesis the following conditions for patient referrals. 1) Services must be personally referred by the attending physician. 2) Referrals are to a physician of the same group or practice. ) Any individual supervised by the referring physician in the hospital or physician that works part-time in the facility and is part of a group practice must comply with all coverage and payment rules regarding Medicare and Medicaid patients. 4) tolerant billing is by the physician playing or supervising the care and treatment of the patient. 5) Regarding a group practice, attending physician under the group must be a member with an charge billing number different from physicians employed with the health facility. ) Third ships company billing companies representing the physician(s) will also be assigned a billing number. These companies have to comply with Medicare re quirements. The task of evaluating referral arrangements by physicians will be challenging, however financial provisions involving physicians can be analyzed using the conditions outlined. The Chief Nursing Officer will receive a monthly report of Medicare and Medicaid referrals. Non- submission will result in immediate termination from the health facility. Discussing fraud and villainy the health industry continues to lose billions.Fraud can range from performing unnecessary medical procedures for insurance gains, to altering patient information and illicitly billing for services not rendered. Also accepting kickbacks for patient referrals, and promoting drugs without authorization. These incidents affect the economy and are potential hazards to the health and safety of patients. An example is medical information illegally altered may receive incorrect treatment or realize existing health benefits are exhausted. Either way another alternative for compliance can address these issu es.A method of enforcement created by the office of the Inspector General (OIG) identified as a bodied Integrity Agreement to improve health care quality and labor compliance to health care guidelines. The term Integrity Agreement focuses on physicians according to one source. Establishing OIG 1976 to imposed action against widespread fraud and abuse in Federal health care programs. These efforts developed a collaborative use of enforcement tools as monetary penalties and exclusions. Corporate Integrity Agreements implemented by the OIG to redeem health care providers under the program to avoid exclusions.Implementing a CIA will be challenging and somewhat complex, especially for birth and reproduction. The sterilisation process, wrongful birth, and wrongful life are areas of interest, and the CIA will have major impact. Physicians play a major role due to misconception by antenatal testing, genetic testing, and laboratories that failed to provide these services. Sterilization fa lls under reproduction and birth is another area likely for fraudulent behavior from the side effectuate patients go through and were not informed by the attending physician.Nevertheless, to address current fraud behaviors and prevent future incidents among physicians, nurses, and medical staff it is necessary to develop strategies to fancy ethical and moral business practices through compliance of various laws that will reduce any risk of legal liability. Although the CIA program contains various features, after careful review and collaboration among executive staff the following requirements will accommodate the needs and requirements that will mitigate incidents of fraud by Developing written policies and standardsInstituting a confidential disclosure program Employing a compliance officer or a compliance committee Implementing an employee training program Restricting employment of ineligible persons Report overpayments, fraudulent behaviors, and ongoing investigations/legal p roceedings Implementation reports are provided annually to the regulatory agency, (Sable, 2013). These requirements should prevent future fraud misconduct by ensuring internal actions and mitigating methods are in place. In conjunction with fraud and abuse is protecting patient information and omplying by all applicable laws. Accessing patient information considered a major subject for health organizations to comply with the Health Insurance Portability and right Act (HIPPA) laws. Patient medical records are vital for treatment and must remain confidential within the federal and state laws. Without authorization the patient Privacy Rules are in violation. The responsibility of Chief Nursing Officer ensures the medical staff training and knowledgeable of health centers policies and procedures to remain in compliance with HIPPA.Often areas overlooked whether accidental or knowledgeable and certain information is discussed or discarded documents. Routine conversation among staff woul d be limited to specific areas where patient information cannot be disclosed. macrocosm areas such as elevators, hallways, or waiting areas are strictly off limits. Many times patients are in surgery or receiving treatment for an illness, family members are waiting for results and often physicians will meet with them in in the public eye(predicate) areas to discuss sensitive information not realizing the conversation can be overheard by others. This is just one example of a disclosure violation.Also what may sound insignificant represents another action that can lead to falling out of information by patient documents thrown in a pan out can that must be shredded to avoid public view. The plan is simple to comply with all necessary laws extensive training provided to the sinless staff is the beginning. One-on-one and group meetings held on a quarterly basis as a tool to prevent abuse and fraudulent behavior. Patient sensitivity is essential in meeting the goals of health center. Laws provide instruction for dealing with fraud cases or any unethical or moral decisions made.To eliminate fraud and abuse continued pressure on the government to establish tougher policies in the delivery of medical and health care services. supererogatory funding for government enforcement agencies will put more pressure on physicians to act responsibly. As physicians become more aware of this fact, he or she should continue to take steps, such as implementing a compliance plan, to ensure the services provided reflect effective documentation for claims of payment. Until doctors, nurses, and other medical staff demonstrate ethical and moral standards, fraud, and abuse will continue to a problem for health organizations. ReferencesFraud and Qui Tam Cases. (2008). Retrieved from http//www. lawyershop. com Healthcare Fraud and Qui Tam Suits. (2008). Retrieved from http//www. lawyershop. com Pietragallo, Gordon, Alfano, Bosick, and Raspanti, LLC. (2013). Health Care Fraud and False Claims. Retrieved from http//www. falseclaimsact. com Cruise, P. L. (n. d. ). Deregulating Health Care Ethics Education. Retrieved from http//www. spaef. com/article Sable, L. (2013). Negotiating Corporate Integrity Agreements. Retrieved from http//www. franchiselawsolutions. com The Qui Tam Team. (2012). Types of Qui Tam Cases. Retrieved from http//www. quitamteam. com