The Role Of Fraud In Healthcare

Healthcare fraud can happen when there are deceitful care providers who do not have their patients’ best interest at heart. There are many different types of healthcare fraud such as, unnecessary or duplicate tests and procedures, to hacking into a patient’s personal medical records to submit false claims ("Healthcare Fraud", 2017). According to, the National Health Care Anti-Fraud Association the most common kind of healthcare fraud are: Medically performing unneeded services for the sole purpose of receiving insurance payments. Accepting kickbacks for patient referrals, this is when a provider or business pays someone to find them new clients as a result the person receives a percentage of every new client they find for the provider or business

Penalties can be but not limited to monetary fees. This kind of penalty can have great effect on any healthcare organization no matter the size of the organization. Per law, the government can recover up to three times the amount of the damages sustained by the claim (Mattie, A., & Ben-Chitrit, R. 2009). With the amendments made in 1986 and 2006, the false claim acts states that even if any number of false claims are combined and submitted together, each separate false claim will result in a penalty. For example, a facility that did not properly bill 500 claims and added improper charges of $1000 they will likely be liable for $500,000 in damages plus a minimum of $2,750,000 for each of the claims submitted (Mattie, A., & Ben-Chitrit, R. 2009). It doesn’t stop their organizations may also face other penalties such as barriers that will not allow their participation in government programs, such as Medicare and Medicaid. If excluded from these government programs it can be devastating to any organization whose patients use this form of insurance or aid. Lastly, the government can carry out organization agreements with stipulations that can make business very costly (Mattie, A., & Ben-Chitrit, R.

Using best practice approach.

Investigations- If we are in any way under investigation we will be forthcoming and cooperate.

Violations of Standards and Conduct

Violations of these standards must be reported immediately to Administration if it is suspected that any administration faculty has violated these standards please contact the fraud abuse hotline at 855-see-abuse. Callers will be kept anonymous.

Generalization of what fraud and abuse is:

Each employee will make sure they do not participate in: submitting claims for undocumented services, up coding, billing for discharge instead of transfers, improper use of modifiers, assumption coding, altered documentation, coding without documentation, unqualified persons billing for services.

Learning activities

Recognizing and reporting fraud and abuse scenarios/case studies

There will be 3 scenarios/case studies and one must identify what is the best answer to each scenario/case study

Explanation of the Standards and Conducts of this organization

Each employee must be able to explain what the standards and conducts of the organization are through a true or false