M8 fraud waste analysis

Overview

In this module, you explored the importance of documenta!on in government compliance and repor!ng. When assisted by

technology, documenta!on becomes easier to capture and maintain, as well as less prone to errors, which in turn improves

the pa!ent experience.

This ac!vity will help you describe how technology supports regulatory compliance in healthcare. It also enables you to

explain how regula!on, fraud, and abuse impact opera!ons and pa!ent care.

Scenario

You work within a healthcare organiza!on as the director of quality, and your chief compliance officer has asked you to create

a memo to be distributed to the en!re organiza!on. They have asked that the memo focus on how an organiza!on can be#er

manage risk to the revenue cycle and healthcare reimbursement by examining ways to reduce fraud, waste, and abuse.

Direc!ons

Create a memo to assess how the following laws and regula!ons can help a healthcare organiza!on reduce fraud, waste, and

abuse and thereby manage risk to the revenue cycle and reimbursement. Also, recommend strategies and technology to help

an organiza!on abide by the laws and regula!ons. Refer to the following laws and regula!ons to guide your response:

False Claims Act

Physician Self-Referral Law

An!-Kickback Statute

An!-Trust Laws

You may refer to the “Ac!vity Reading” resource in the module resources sec!on to be#er understand how a memo is

structured. If you need wri!ng support, access the Online Wri!ng Center through the Academic Support module of your

course.

Specifically, you must address the following rubric criteria:

1. False Claims Act: Analyze the impact of the False Claims Act on the organiza!on’s reimbursement, coding, and

strategic planning. Consider the following ques!ons to guide your response:

What are the provisions of the False Claims Act?

What penal!es could an organiza!on face for viola!ng the Act?

2. Physician Self-Referral Law: Analyze the impact of the Physician Self-Referral Law on a healthcare organiza!on’s

reimbursement, revenue cycle, and strategic planning. Consider the following ques!ons to guide your response:

What are the features of the Physician Self-Referral Law?

How does this law help prevent fraud and abuse in healthcare?

3. An!-Kickback Statute: Analyze the impact of the An!-Kickback Statute on healthcare reimbursement and referrals.

Consider the following ques!ons to guide your response:

How is the An!-Kickback Statute different from the Physician Self-Referral Law?

What kind of financial penal!es would be a#racted by the viola!on of this statute?

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4. An!-Trust Laws: Analyze the impact of the An!-Trust Laws on a healthcare organiza!on’s financial performance and

strategic planning. Consider the following ques!ons to guide your response:

What are the premises of the An!-Trust Laws?

How do the An!-Trust Laws help prevent fraud and abuse in healthcare?

5. Recommenda!ons: Recommend strategies and technology to reduce opera!onal risk and promote opera!onal

efficiencies by integra!ng the regula!ons that prevent fraud, waste, and abuse. Consider the following ques!ons to

guide your response:

What measures can you take to incorporate the provisions of the False Claims Act and the An!-Trust Laws?

What process changes will help the organiza!on comply more easily with the Physician Self-Referral Law and

the An!-Kickback Statute?

All the claims in your deliverable should be evidence based. Your cita!ons should be from your independent search for

evidence (not from the textbook or module resources) of credible sources and be current within the last five years. You are

required to cite a minimum of two sources, at least one of which should be separate from your own research. Refer to the IHP

630 Library Guide located in the Start Here sec!on of the course for addi!onal support.

What to Submit

Submit your memo as a 3- to 4-page Microso% Word document with double spacing, 12-point Times New Roman font, and

one-inch margins. Also include a !tle page. Sources should be cited according to APA style.

Criteria Exemplary (100%) Proficient (90%) Needs

Improvement (70%) Not Evident (0%) Value

False Claims Act Exceeds proficiency in an excep!onally clear and insigh&ul manner, using industry-specific language

Analyzes the impact of the False Claims Act on a healthcare organiza!on’s reimbursement, coding, and strategic planning

Shows progress toward proficiency, but with errors or omissions

Does not a#empt criterion

15

Physician Self- Referral Law

Exceeds proficiency in an excep!onally clear and insigh&ul manner, using industry-specific language

Analyzes the impact of the Physician Self- Referral Law on a healthcare organiza!on’s reimbursement, revenue cycle, and strategic planning

Shows progress toward proficiency, but with errors or omissions

Does not a#empt criterion

15

An!-Kickback Statute

Exceeds proficiency in an excep!onally clear and insigh&ul manner, using industry-specific

Analyzes the impact of the An!- Kickback Statute on healthcare reimbursement and

Shows progress toward proficiency, but with errors or omissions

Does not a#empt criterion

15

Module Eight Ac!vity: Fraud, Waste, and Abuse Reduc!on Memo Rubric

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language referrals

An!-Trust Laws Exceeds proficiency in an excep!onally clear and insigh&ul manner, using industry-specific language

Analyzes the impact of the An!- Trust Laws on a healthcare organiza!on’s financial performance and strategic planning

Shows progress toward proficiency, but with errors or omissions

Does not a#empt criterion

15

Recommenda!ons Exceeds proficiency in an excep!onally clear and insigh&ul manner, using industry-specific language

Recommends strategies and technology to reduce opera!onal risk and promote opera!onal efficiencies by integra!ng the regula!ons that prevent fraud, waste, and abuse

Shows progress toward proficiency, but with errors or omissions

Does not a#empt criterion

15

Ar!cula!on of Response

Exceeds proficiency in an excep!onally clear and insigh&ul manner

Clearly conveys meaning with correct grammar, sentence structure, and spelling, demonstra!ng an understanding of audience and purpose

Shows progress toward proficiency, but with errors in grammar, sentence structure, and spelling, nega!vely impac!ng readability

Submission has cri!cal errors in grammar, sentence structure, and spelling, preven!ng understanding of ideas

10

Scholarly and Professional

Sources

Incorporates more than two scholarly, current (within the last five years) sources, or use of sources is excep!onally insigh&ul

Incorporates two scholarly, current (within the last five years) sources that support claims

Incorporates fewer than two scholarly, current (within the last five years) sources, or not all sources support claims

Does not incorporate sources

10

APA Style Formats in-text cita!ons and reference list according to APA style with no errors

Formats in-text cita!ons and reference list according to APA style with fewer than five errors

Formats in-text cita!ons and reference list according to APA style with five or more errors

Does not format in- text cita!ons and reference list according to APA style

5

Total: 100%

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