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In the past 5 years how has fraud and abuse affected the U.S. healthcare system
Fraud and abuse in the healthcare system
Fraud and abuse in the healthcare system
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1. What is the Centers for Medicare and Medicaid Services (CMS)? What is their function? Discuss this in detail. CMS also known as the Health Care Financing Administration (HCFA) is a federal agency with the United States Department of Health and Human service that administer Medicare programs and works in partnership with the state government to administer Medicaid. The centers provide healthcare security for aged and disabled people in the country. They help by finding new ways to pay for and deliver care that can lower cost and improve care. CMS has partnerships with several organizations such as Territorial and Tribal governments, advocacy groups and many other organizations. 4. If you know of fraud or abuse occurring, what should you
CAH needs to add value to be able get more patients that will increase the profits for CAH. One way for CAH to add value would be to focus on disease management. Take diabetes, the patient would see a primary care doctor, got to an optometrist and get their labs done together and the providers would communicate with each other to make sure the patient is getting the care they need. The primary care doctor could make sure that the patients are reminded of when their next appointments are. Using web-based health also would help to add value ("Capturing the Value from Value-Added Services"). The Veterans Affairs Administration uses a web-based health notification system to allow patients to know what their lab results are and to refill prescriptions from their home that would then be mailed to
Membership Services (MSD) at Kaiser Permanente used to be a modest department of sixty staff. However, over the past few years the department has doubled in size, creating minor departmental reorganization. In addition the increase of departmental staffing, several challenges became apparent. The changes included primary job function, as well as the introduction of new network system software which slowed down the processes of other departments. These departments included Claims (who pay the bills for service providers outside of the Kaiser Permanente network), and Patient Business Services (who send invoices to members for services received within Kaiser Permanente). Due to the unforeseen challenges created by the system upgrade, it was decided that MSD would process the calls for both of the affected departments. Unfortunately, this created a catastrophic event of MSD receiving numerous phone calls from upset members—who had received bills a year after the service had been provided. The average Monday call volume had risen from 1,800 to 2,600 calls per day. The average handling time for each phone call had risen as well—from an acceptable standard of 5.6 minutes to an unfavorable 7.2 minutes. The department continued to be kept inundated with these types of calls for the two years that these changes have been effect.
Health Care workers are constantly faced with legal and ethical issues every day during the course of their work. It is important that the health care workers have a clear understanding of these legal and ethical issues that they will face (1). In the case study analysed key legal and ethical issues arise during the initial decision-making of the incident, when the second ambulance crew arrived, throughout the treatment and during the transfer of patient to the hospital. The ethical issues in this case can be described as what the paramedic believes is the right thing to do for the patient and the legal issues control what the law describes that the paramedic should do in this situation (2, 3). It is therefore important that paramedics also
Niles, Nancy J. Basics of the U.S. Health Care System. Sudbury, MA: Jones and Bartlett, 2011. Print.
Medicare is a social policy many of our seniors look to for their stability when they reach 65
...0. CMS-1500 is the basic form that has been set by Center for Medicare and Medicaid services and is used by most outpatient clinics. CMS-1450 is the form that is used hospitals to claim reimbursement for hospital visits. While CMS-1500 is used for patients who are under Medicare Part B, CMS-1450 is used for patients insured under Medicare Part A. Some of the charges that need to be claimed using CMS 1500 are ambulatory surgery performed in a certified Ambulatory Surgery Center, all hospital based clinics, and hospital based primary care office. Furthermore, some of the charges that need to be claimed in CMS-1450 are emergency department visits, ancillary department visits, outpatients services such as infusion therapy or observation, all services rendered during an inpatient visit, and any pathology service provided regardless of patients’ presence (Ferenc, 2013).
Since the initiation of the Affordable Care Act in 2010, Americans have been put back in charge of their individual health care. Under this new law, a health insurance marketplace provides a haven for individuals without insurance to gain coverage. Just this year, citizens found out early whether they qualified for Medicare or the CHIP formally known as the Children’s Health Insurance Program. So much is to be learned about the Affordable Care act and this paper provides the roles of the different governmental branches, along with other important factors associated with this law.
Barton, P.L. (2010). Understanding the U.S. health services system. (4th ed). Chicago, IL: Health Administration Press.
Medicare and Medicaid together "are the single biggest contributor to [the United States] long term [budget] deficit." This idea was expressed by President Obama during his 2011 state of the Union Speech. After saying this, the president said that health care costs need to be reduced, including these two services. Medicare and Medicaid are beneficial to those who receive their services, and the criteria for eligibility currently allow many to qualify for either program. This is most likely the cause of the major deficit that the president spoke of. However, downsizing or eliminating these programs to lessen the deficit will affect many people and their ability to receive healthcare.
Niles, N. J. (2011). Basics of the U.S. health care system. Sudbury, MA: Jones and Bartlett.
Medicare is the nation’s largest health insurance program. Generally, you are eligible for Medicare if you or your spouse worked for at least ten years in Medicare-covered employment and you are 65 years old and a citizen or permanent resident of the United States. Medicare-covered services include hospital insurance, inpatient hospital care, skilled nursing facility care, home health care, hospice care, and medical insurance (Medicare U.S.) With such an encompassing effect on the health insurance field, Medicare provides a haven for older individuals, and end-stage renal disease (ESRD) patients who require the best medical care for whatever possible reason. The only problem with this scenario is that doctors are turning many older patients away because they have Medicare. Why do doctors turn away Medicare patients? Is there a reason why certain doctors turn away certain patients?
Medicare and Medicaid are two of the United States largest broken systems, which must sustain themselves in order to provide care to their beneficiaries. Both Medicare and Medicaid are funding by a joint effort between the federal government and the local state government. If and when these governments choose to cut funding or reduce spending, Medicare and Medicaid take the biggest hit. Most people see these two benefits as one in the same, two benefits the government takes out of their pay check to help fund health care. While the government does deduct a sum from paychecks everywhere, Medicare and Medicaid are very two very different programs.
Medicare and Medicaid are programs that have been developed to assist Americans in attainment of quality health care. Both programs were established in 1965 and are federally supported to provide health care coverage to vulnerable populations such as the elderly, the disabled, and people with low incomes. Both Medicare and Medicaid are federally mandated and determine coverage under each program; both are run by the Centers for Medicare & Medicaid Services, a federal agency ("What is Medicare? What is Medicaid?” 2008).
Health reform and health policy has taken over in the United States in recent years. Medicaid is one of the top policies being implemented throughout our nation today. To understand how Medicaid and federalism cross paths with each other one must understand the basic definitions and concepts each one brings. Federalism is “system of government in which the same territory is controlled by two levels of government. Generally, an overarching national government governs issues that affect the entire country, and smaller subdivisions govern issues of local concern.” In short, federalism is a government system that has an overseeing central government over state government. While, “Medicaid is a health insurance program for low-income individuals and families who cannot afford health care costs. Medicaid serves low-income parents, children, seniors, and people with disabilities.” Medicaid is a test based welfare program for United States Citizens. Now the question is how does Medicaid intersect with federalism? These two intersect because Medicaid is a need-based program that is funded by the federal government and the state government and administered at the state level. The issue with Medicaid is that if it expands then a crowding-out effect may occur. Meaning, that the more the government spends on Medicaid then less they would be able to spend on other programs such as: education, transportation, or other state priorities. Medicaid is supposed to provide access to health insurance for approximately half of our nations uninsured citizens. Without Medicaid a vast amount of low-income citizens will go without having a healthcare insurance plan.
After analyzing the case studies of Tufts Health Plan Medicare, Innovative Marketing Resources and BrightGauge Software, it became clear that those three companies only reached success once they defined the objectives for their communication vehicles, in this case their websites, and established specific KPI’s to measure progress towards their goals. As Paine (2011) notes, “In general, those organizations that measure do better than those that don’t” (p. 16).