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

("Healthcare Fraud", 2017). Falsifying patient diagnosis to defend mistreatment of test, and surgeries. More importantly billing for procedures that were never performed. This is done by using real patient information on false patient documents ("Healthcare Fraud", 2017).
There are laws in place to make sure that providers and organizations are not conducting fraud and abuse practices. The Anti-Kickback Statue prohibits a provider or organization to knowingly and willfully solicit items or services for payment through Medicare or Medicaid. Also, it is a violation of the Anti-Kickback Statue to bribe or pay for a referral of a Medicare patient (Burns, 2012). Providers who engage in these kind of arrangements, such as payments of financial incentives in connection with physician recruitment, will also be considered fraud through the Anti-Kickback Statue (Burns, 2012). The Stark Physician Self-Referral Law (Stark) prohibits patient referrals through physicians to any health service providers in which the physicians have a financial relationship (Burns, 2012). Also, there is the False Claims Act (FCA) this law prohibits any provider, physician, or organization to knowingly submit a false claim to the government, such as a Medicaid or Medicare claim for a service different from the one that was provided (Burns, 2012).
The HHS Office of the Inspector General, which are in cooperation of the Department of Justice, devotes a considerable amount of time and resources to enforce federal fraud and abuse laws (Burns, 2012). State authorities can also bring enforcement actions against organizations; many states have their own fraud and abuse statutes that they follow. Government authorities are not the only units involved in enforcing fraud and abuse laws. However, many False Claim Acts law suits are not started by government units, but by individual employees called whistle-blowers those individuals are pursuant to the “qui tam” provisions of the false claims act (Burns, 2012). Those Individuals who bring qui tam actions inform the government that there is potentially a violation that need addressed and then they share in any proceeds the government acquires from a judgment from given information or settlement. The false claims’ qui tam provision greatly increases the probability of detection of false claims (Burns, 2012).
Civil damages under the false claims act are significant.

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.

2009).
Training Program
What is Fraud and Abuse
Fraud is when someone knowingly and willfully commit, or attempt to commit, a crime or devise a plan to defraud any health care benefit program by committing the act of false or fraudulent pretenses, representations, or promises. Abuse includes but are not limited to certain actions that can, directly or indirectly, result in: unneeded costs to the Medicaid - Medicare Program for improper payment, or payment of services that does not meet the required standards of care, or services rendered that are not medically necessary.
Standards and Conduct is to ensure that all medical coding and billing staff and this organization stay in compliance with federal law concerning fraud and abuse within the healthcare sector.
To stay in compliance, we must always have:
Accurate Claims and coding – Our organization does not bill for services and other items rendered or documented according to each client’s medical records
Accurate Organization records- All billing records are properly and accurately filed and documented in regards to all business transactions.
Kickback- Our organization does not partake in providing payment or incentives for client referrals. We also, do not participate in other activities that will violate the Anti-Kickback statue.
Honesty- Our organization follows all that is ethical within the healthcare field.

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

questionnaire
Summarizing the False Claims Act/Anti-Kickback statue
A summary of the false claims act and the anti-kickback statue be conducted with multiple choice answers.
The fraud and abuse training for all medical billing and coding must occur annually and all those going through orientation/new hires must take the fraud and abuse training within 30 days of hire date. This is including but not limited chief executive and senior administrators or managers.