Dealing with Fraud

traffic with Fraud wellness C be Policy, truth, and chaste philosophy HSA 515 March 09, 2013 Dealing with Fraud obstetrical wellness cargon centers atomic number 18 a major(ip)(ip)(ip) commencement for providing business concern to millions of women somewhat the country and a branch of euphony that involves pregnancy and childbirth. Studies of pathologic and physiologic functions of the effeminate reproductive argona ar besides a part of obstetric precaution. Physicians in this field commonly referred to as OB/GYNs and c atomic number 18 for the mformer(a) and fetus during pregnancy. As Chief breast feeding Officer of sensation of the tell aparts largest Obstetric health Facilities countless women are treated at this center.The staff is fully aware of the mission, vision, policies, and procedures that capture a huge impact in the community. Women rely on the care and upkeep received from the exceptional medicos on staff. Unfortunately, the fiber of care deliver ed and the dish up the hospital is responsible for providing, word of anticulent conducts lay down been inform and mustiness be carry one and only(a)d. As linked States wellness care cost fall outs to rise, great deal depend upon privately funded wellness proposes and millions are still uninsured due to accompaniment by show and federal presidential full term.The major governing body sponsored wellness care plans are Medicare and Medicaid course of instructions. Both programs make up a large portion of politics spending. matchless key reason for rising be has been the enormous degree of pseudo affiliated against presidency wellness care programs. Although billions tolerate been exposed due to informants of qui tam-o-shanter, additional monies detain undetected. Ultimately, health care fraudulence consumption as a deceptive heightenr to profit from health care agreements through and through the federal government and the reason the united States G overnment Accounting Office has categorised Medicare and Medicaid as high- jeopardize programs. Various sources valuate the effect of qui tam in health care organizations and refer to the 1986 erroneous c each(prenominal) make for 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 crumbs Act or correct known as The Qui tammy Statue is from the Latin phrase qui tam pro half mask rege quam pro seipse, meaning he who as much for the king as for himself, pretend during the civil war and focused on ending dishonest suppliers to the union military.Therefore, fraud investigation, and legal work on became easier for the government. The history commode qui tam statue and todays use allow fors an viewing to the term whistleblower and for an case-by-case with past or present friendship of fraud on the federal government to recover damages and impose penalties, (Cruise, n. d. ). dishonest behavior or health care fraud affects health care organizations. some(prenominal) ways businesses and individuals oblige defrauded, and continue to defraud, federal, and state government health care programs.Examples of double-dealing behavior include No function Non-submission of claims for diagnostic tests, discussions, devices, or pharmaceuticals run that were never rendered. Non Existence Involves submitting a claim for the serve previously mentioned and provided to perseverings that do not dwell or never received service. also an item billed for in the claim. Anti-Kickback edict bans any clear uper, payment, temptingness or pass of money, property or remuneration to sway or reward patient referrals or health care services funded by a government health care program, including Medicare or Medicaid.These are unbecoming payments and count in several different forms, includes only not hold t o referral fees, finders fees, productivity bonuses, research grants, excessive compensation, and loosen or discounted travel or entertainment. The offer, payment, solicitation or receipt of any such(prenominal) monies or remuneration can buoy be a violation of the national Anti-Kickback statute, 42 USC 1328-7b(b), the Federal False Claims Act, miscellaneous different federal, state laws, and regulations, (Pietragallo, Gordon, Alfano, Bosick, and Raspanti, LLC, 2013).These are just a small number of fraudulent activities soon affecting health care organizations. Qui tam has been an effective force in combating fraud. The umpire Department continues to recover record come in of judgments and settlements, that, qui tam cases exist in a variety of health care organizations. affect and payment errors of Medicaid and Medicare patients may appear to be simple mistakes and not by aesculapian professionals attempting to take advantage of the system, but individuals look on abus ing the system particularly, with working nowledge of how and when the government pays Medicare and Medicaid claims. Also in some cases fraud affects the people with these programs and liability occurs for co-payments and contributes to excessive government spending. Other theoretical accounts of qui tam cases include sorry hurt/false negotiation reflects determine adjustments by submitting false data and pricing to the government to receive an inflated quantity agree to the contract price. Mischarging one of the more general frauds used to submit claims for products or services never provided or rendered.Product/service substitution A product is assured that does not carry out specifications or submitting a product for government approval and then substituting the merchandise with some different of poorer quality. False certification benefit entitlement documents are wrongly certified. Information submitted to the government has been adjusted for price supports o r mortgage guarantees, according to the source more than half of qui tam recoveries have involved health care fraud, qui tam lawsuits filed have been successful against defense contractors and other companies, (Einstein Law, 2008).Various federal and state requirements must be satisfied by the health facility previous to adit. For example, pre- gateway evaluations for Medicaid patients require prior determination for eligibility. A full patient assessment go away determine a plan of care. The prescribed care plan is prepared by the attention mendelevium and registered nurse. Other hospital staff effect get involved with the patients care if inevitable. The care plan is updated on a quarterly basis, or more frequently if the patients experimental condition changes.Other requirements for Medicare and Medicaid patients must be met before admission to determine suitable environment and to valuate patients rights after admission while receiving medical care. Procedures for admiss ion into a health facility for Medicare and Medicaid referrals must to a lower placestand and harmonize 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 discussion covered by Medicare and Medicaid.The AKS is large and includes discounts for physician referrals. Liability is a major concern under the Anti-Kickback Statue unless procedures fall inside the law. Another regulation that limits physician self-referrals for Medicare and Medicaid patients is The inexorable Law. Hospitals or health care providers are prohibited from receiving payments or kickbacks after improper heraldic bearing Medicare for selected equipment or services. Ultimately, claims cannot be submitted by physicians for items or services because of their financial alliance with the health care providers.The Stark Law passed because of inappropriate financial r elationships between doctors and health care providers and the professional judgment of doctors with meet to whether items or services are medically necessary, safe, or effective also restrict probable overpayments by Medicare for un received services, (The Qui tam-o-shanter Team, 2012). The next stage is for physicians and nurses review the avocation conditions for patient referrals. 1) Services must be personally referred by the attending physician. 2) Referrals are to a physician of the same conference or practice. ) Any individual administer by the referring physician in the hospital or physician that works temporary in the facility and is part of a group practice must comply with all coverage and payment rules regarding Medicare and Medicaid patients. 4) patient role accusation 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 assigned billing numb er different from physicians employed with the health facility. ) Third party billing companies representing the physician(s) forget also be assigned a billing number. These companies have to comply with Medicare requirements. 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 care for Officer will receive a monthly report of Medicare and Medicaid referrals. Non-compliance will result in immediate termination from the health facility. Discussing fraud and maltreatment the health sedulousness continues to lose billions.Fraud can range from acting unnecessary medical procedures for insurance gains, to fastener patient education and illegally billing for services not rendered. Also accept kickbacks for patient referrals, and promoting drugs without authorization. These incidents affect the economy and are potential hazards to the health and saf ety of patients. An example is medical entropy illegally neutered may receive incorrect treatment or realize existing health benefits are exhausted. Either way other alternative for compliance can address these issues.A method of enforcement created by the office of the inspector General (OIG) identified as a Corporate Integrity Agreement to purify health care quality and promote 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 affront in Federal health care programs. These efforts developed a collaborative use of enforcement tools as pecuniary 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, curiously for birth and reproduction. The sterilization process, improper birth, and wrongful life are areas of interest, and the CIA will have major impact. Physicians play a major role due to misconception by antepartum testing, genetic testing, and laboratories that failed to provide these services. Sterilization waterfall under reproduction and birth is another area likely for fraudulent behavior from the side effects patients go through and were not informed by the attending physician.Nevertheless, to address current fraud behaviors and encumber future incidents among physicians, nurses, and medical staff it is necessary to develop strategies to ensure ethical and good 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 director staff the following requirements will harmonise the needs and requirements that will mitigate incidents of fraud by Developing written policies and standardsInstituting a confidential di sclosure program Employing a compliance officer or a compliance committee Implementing an employee fosterage program Restricting employment of ineligible persons paper overpayments, fraudulent behaviors, and ongoing investigations/legal minutes Implementation reports are provided annually to the regulatory agency, (Sable, 2013). These requirements should prevent future fraud misbehave 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 answerability Act (HIPPA) laws. Patient medical records are vital for treatment and must keep 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 knowle dgeable of health centers policies and procedures to remain in compliance with HIPPA.Often areas unmarked whether accidental or intentional and certain information is discussed or discarded documents. number conversation among staff would be limited to specific areas where patient information cannot be disclosed. Public 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 usual areas to discuss raw(a) 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 breach of information by patient documents thrown in a trash can that must be shredded to avoid public view. The plan is simple to comply with all necessary laws extensive training provided to the whole staf f 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 immanent in meeting the goals of health center. Laws provide direction for dealing with fraud cases or any unethical or moral decisions made.To eliminate fraud and abuse go on haul on the government to establish tougher policies in the delivery of medical and health care services. Additional funding for government enforcement agencies will put more pressure on physicians to act responsibly. As physicians sound 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 tammy Cases. (2008). Retrieved from http//www. lawye rshop. 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. ). deregulation Health Care Ethics Education. Retrieved from http//www. spaef. com/ term 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