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Challenges of healthcare fraud in the united states
Challenges of healthcare fraud in the united states
Challenges of healthcare fraud in the united states
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The following is a summary of both the state’s and Community First Health Plan’s (“Community First”) rights and responsibilities under the Texas Medicaid Managed Care rules with respect to audits and overpayment recoupments. We have attempted to address the various issues and questions that have been raised by SPA.
I. Medicare managed care organizations.
In Texas, most Medicaid services and all Children’s Health Insurance Programs (“CHIP”) services are delivered through managed care. The Texas Health and Human Services Commission (“HHSC”) contracts with state-licensed managed care organizations (“MCOs”), and pays them a monthly amount to coordinate health services for Medicaid or CHIP members enrolled in their plans. The MCOs contract
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establish and maintain a special investigative unit (“SIU”) to investigate cases of suspected fraud, waste, and abuse (“FWA”) by recipients and providers in the Medicaid program; and
B. develop and annually submit for approval a plan describing how it will prevent and reduce FWA. The HHSC-OIG is authorized to approve each MCO’s annual plan. (1 TAC §353.501) HHSC requires its MCOs to continuously monitor compliance as well as investigate possible non-compliance, and has given the SIUs wide latitude to carry out those responsibilities. Specifically, an MCO must implement the following on-going procedures to detect possible FWA: (1) audits to monitor compliance and to assist in detecting and identifying program violations and possible FWA overpayments; (2) monitoring of service patterns; (3) hotline or other reporting mechanism; (4) random payment review of providers’ claims; (5) edits or other evaluation techniques; (6) routine validation of MCO data; and (7) verification that members actually received the services. (1 TAC
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The Provider Manual explains that the function of SIU/Coding and Compliance is to implement Community First’s FWA plan and to assist in detecting and identifying possible Medicaid program violations and FWA overpayments. (Provider Manual, p. 129) Coding and Compliance performs its audits through:
A. data matching - using available sources including the AMA and CMS, Community First compares procedures, treatments and other billed services for reasonableness; and
B. trending and statistical analysis -Community First provides its vendor, EDI Watch, with three years of electronic claims data, which EDI Watch processes on a quarterly basis. Coding and Compliance then applies edits, flags, and fraud rules to build routine activity profiles, and conducts statistical analysis of that information to identify unusual trends (i.e.; high percentages of flags, utilization, and/or potential overpayments) in weekly, monthly, and yearly patterns (1) across all claims, (2) within a particular list or group of providers, and (3) for a particular provider or patient. (Provider Manual, pp.
With the passage of the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) has initiated reimbursement based off of patient satisfaction scores (Murphy, 2014). In fact, “CMS plans to base 30% of hospitals ' scores under the value-based purchasing initiative on patient responses to the Hospital Consumer Assessment of Healthcare Providers and Systems survey, or HCAHPS, which measures patient satisfaction” (Daly, 2011, p. 30). Consequently, a hospital’s HCAHPS score could influence 1% of a Medicare’s hospital reimbursement, which could cost between $500,000 and $850,000, depending on the organization (Murphy, 2014).
Under the Social Security Act, it is required that hospitals report quality measures for a set of 10 indicators. If hospitals do not report quality measures to CMS there is a reduction in payments. In the hospital readmission area of investigation, OIG reviews Medicare claims in hospital readmission cases to identify trends and oversights of cases. Readmissions are cases in which the beneficiary is readmitted to the hospital less than 31 days after being discharged from the hospital. Hospitals are only entitled to one diagnosed-related group payment if there is a same-day readmission for symptoms related to prior hospital stay. Quality improvement organizations are required to review hospital readmission cases also this is to see if standard of care are met. For coded conditions as present on admission, it is required for acute hospital to report these diagnoses on Medicare claims. The OIG will review Medicare claims for types of facility or providers most frequently transferring patients to hospital
The federal government has taken a stance to standardized care by creating incentive programs that are mandated under the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009. This act encourages healthcare providers and healthcare institutions to adopt Meaningful use in order to receive incentives from Medicare and Medicaid. Meaningful use is the adoption of a certified health record system that acquires or obtains specified objectives about a patient. The objectives or measures are considered gold standard practices with the EHR system. Examples of the measures include data entry of vital signs, demographics, allergies, entering medical orders, providing patients with electronic copies of their records, and many more pertinent information regarding the patient (Friedman et al, 2013, p.1560).
It is enthralling to note that in spite of the advances in healthcare systems, such as our hospital’s ability to provide patients with lower cost, managed One being the Health Maintenance Organizations (HMO), which was first proposed in the 1960s by Dr. Paul Elwood in the "Health Maintenance Strategy”. The HMO concept was created to decrease increasing health care costs and was set in law as the Health Maintenance Organization Act of 1973, after promotion from the Nixon Administration. HMO would, in exchange for a fee, allow members access to employed physicians and facilities. In return, the HMO received market access and could earn federal development funds.
Under Obamacare, Texas would be an ordinary constitute of the federal government, carrying out the schedule of the United States Department of Health. The major pieces of the Afforadable Care Act do not become active for a few years but Texas must do everything it can to redesign, abolish or dismantle it. Texas officials must also realize that we are not a messenger for the federal government. We are a powerful, self-sufficient state with the power to control our own healthcare system. There is entirely nothing that forces Texas to help force us to use this foolish legislation. Quite frankly, Texas needs to make the most of opportunities to use its authority to create better solutions than a one size fits all federal mandated healthcare. Texas must do what is right for the people of Texas.
In December 2011, Texas Health and Human Services Commission (HHSC) received federal approval of a Medicaid Section 1115(a) Demonstration Waiver, entitled “Texas Healthcare Transformation and Quality Improvement Program,” for the period starting with December 12, 2011 through September 20, 2016. The main objective of the 1115 Waiver is to improve access to and quality of health care by expanding Medicaid managed care programs and promoting health care delivery system reforms while containing cost growth. Specifically, the Waiver created two new pools of funding—Uncompensated Care (UC) and Delivery System Redesign and Innovation Payment (DSRIP) pools—by redirecting funds that were available under the old Upper Payment Limit (UPL) payment methodology. DSRIP funding is used to offer financial incentives to health care providers that develop and implement projects aimed at improving how care is delivered to low-income populations. Specifically, the providers (often referred to as the “performing providers” or “performers”) propose and execute projects like programs, strategies, and investments designed to enhance access to health care, quality of health care, cost-effectiveness of services, and health of the patients and families served.
Rodwin, M. (1996). Consumer protection and managed care: issues, reform proposals, and trade-offs. Houston Law Review, 32(1319), 1319-1381
Health Care Fraud and Abuse Control Program. (2003). Annual Report For FY 2002. Office of the Inspector General, U.S. Department of Health and Human Services website. Retrieved May 26, 2011, from http://oig.hhs.gov/publications/docs/hcfac/HCFAC%20Annual%20Report%20FY%202002.htm.
Health Maintenance Organizations, or HMO’s, are a very important part of the American health care system. Also referred to as managed care programs, HMO's are combinations of doctors and insurance companies that are formed into one organization. This organization provides treatment to its members at fixed costs and decides on what treatment, if any, will be given based on the patient's or doctor's current health plan. Sometimes, no treatment is given at all. HMO's main concerns are to control costs and supposedly provide the best possible treatment to their patients. But it seems to the naked eye that instead their main goal is to get more people enrolled so that they can maintain or raise current premiums paid by consumers using their service. For HMO's, profit comes first- not patients' lives.
In conclusion, managed care integrates the functions of financing, insurance, delivery, and payment within an organization. It also exercises formal control over utilization. Managed care is viewed as accepting the lowest competitive bid for services rendered. Today, HMOs and PPOs are the most common and widely used models for managed care. Although managed care is here to stay, it requires revision in some areas. Challenges that are to be faced include double agentry, fidelity, confidentiality, honesty, and vulnerability. With the help and guidance of health information professionals, managed care will continue to escalade and become better for all.
Sec. 531.102 (f-1) requires the IG to complete a full investigation of a complaint or allegation of Medicaid fraud or abuse against a provider not later than the 180th day after the date the full investigation begins unless the office determines that more time is needed to complete the
Medicaid is a broken system that is largely failing to serve its beneficiary’s needs. Despite its chronic failures to deliver quality health care, Medicaid is seemingly running up a gigantic tab for tax payers (Frogue, 2003). Medicaid’s budget woes are secondary to its insignificant structure, leaving its beneficiaries with limited choices, when arranging for their own health care. Instead, regulations are set in order to drive costs down; instead of allowing Medicaid beneficiaries free rein to choose whom they will seek care from (Frogue, 2003)
Miller, J. (2013). Payers rethink utilization costs. Managed Healthcare Executive, 23(11), 9-9,15. Retrieved from http://search.proquest.com/docview/1458614037?accountid=36202
Medicare Publications, http://www.medicare.gov/Publications/Pubs/pdf/11467.pdf Kenney, G. M. & Cook, A. (2010). Potential Impacts Of Alternative Health Care Reform Proposals For Children With Medicaid And Chip Coverage. The Urban Institute Health Policy Center. Retrieved August 20, 2010 from http://www.urban.org/uploadedpdf/411993_CHIP_coverage.pdf Explaining Health Care Reform: Questions About Medicaid’s Role. (2010). The Kaiser Family Foundation.
Healthcare services have been on the rise for over 10 years now. According to a 2012 consumer alert, the industry provided $2.26 trillion in payments for more than four billion health insurance benefit claims in the year 2011(Fraud in Health Care). The bulk of the claims and the mainstream of fraud and abuse stem from the Medicare system professionals, who are knowledgeable about the process and persuade new clients into handing over their pertinent information in hopes of deception and illegitimate claims. Multiple and double billing, fraudulent prescriptions, are some of the major flaws in this organization that has made the healthcare services industry curdle. (AGHAEGBUNA, 2011) This is a non-violet crime and is often committed by very educated people including business people, hospital, doctors, and administrators.