DQ 4-2
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Response4-2.docx4-2 Responses
1.
Re: Topic 4 DQ 2
Fraud and negligence are closely related. Negligent behaviors include acts of commission and omission. "Commission of an act would include...performing the wrong surgical procedure" (Pozgar & Santucci, 2016, p. 65). Some examples related to the previous statement are: performing unnessary surgeries on patients under Medicare, signing prescriptions for patients never seen, or inflating charges for inpatient or outpatient care (Rudman, et al, 2009). This includes inflating insurance claims and false reporting/charting. "Healthcare fraud is defined as knowingly, and willfully executing or attempting to execute a scheme...to defraud any healthcare benefit program or to obtain by means of false or fradulent pretenses, representations, or promises any of the money or property owned...by any healthcare benefit program" (Rudman, et al, 2009). The Stark Law and Antikickback Statute help prevent physician fraud.
"Abuse is similar to fraud, except that the investigator cannot establish the act knowingly, willingly, and intentionally" (Rudman, et al, 2009). A form of abuse is abandonment. "It can be the result of a personality conflict or pure negligence in following up on the patient's care needs" (Pozgar & Santucci, 2016, p. 249). Simply inadequate care, such as not seeing a patient daily, can also be a form of abuse (Pozgar & Santucci, 2016, p. 254). Performing unnecessary medical tests is abuse. Physical forms of abuse include unnecessary restraints, forcible medication administration, and literal verbal or physical abuse to patients.
A compliance committee serves to help a healthcare facillity adhere to federal, state, and local regulations, as well as hospital policies. They can also serve as educators and advisors for billing, payments, and all patient documentation. As educators, they can provide hospital staff with continuing education and updates on regulation compliance. Because there are so many regulations in healthcare, a committee is not only helpful, but necessary. It is a big job, and their main role should be education. Education is the best way to prevent errors.
Pozgar, G. D., & Santucci, N. M. (2016). Legal Aspects of Health Care Administration. (12th ed). Burlington, MA:
Jones & Bartlett Learning.
Rudman, W. J., Eberhardt, J. S., 3rd, Pierce, W., & Hart-Hester, S. (2009). Healthcare fraud and abuse.
Perspectives in health information management, 6(Fall), 1g.
2.
Fraudulent or abusive behavior in health care is when a provider or consumer intentionally submits, or is the cause of someone else submitting, false or misleading information to determine the amount of payable healthcare benefits. Some of these behaviors or actions include: fraudulent billing for services that were not delivered; falsifying diagnosis’s for unnecessary tests, surgeries, or other procedures; misrepresentation of procedures for the purpose of billing for services that would not otherwise be covered (such as cosmetic surgery); upcoding services; upcoding medical supplies; unbundling (billing for procedures separately); billing unnecessary services; accepting kickbacks for referrals; and overbilling (Pozgar & Santucci, 2016).
The responsibilities of a compliance committee include developing auditing policies and procedures to prevent, detect, deter, and report fraud. Safeguarding assets and ensuring that the functions of financial reporting are kept up with acceptable accounting principles, as well as reviewing and determining the reliability and integrity of the financial and operating information. If the committee fails to question representations, it could result in committee malfeasance and the committee could be held liable for failure to understand and know what they are responsible for identifying (Pozgar & Santucci, 2016).
Pozgar, G.D. & Santucci, N.M. (2016). Legal Aspects of Health Care Administration (12th ed.). Burlington, MA: Jones & Bartlett Learning.
3.
1 posts
Re: Topic 4 DQ 2
Healthcare fraud and abuse cases cost the industry billions of dollars a year. Without processes in place to detect and prevent fraudulent activities, healthcare providers could face an investigation that may cost them their reputation and revenue.
Fraud is defined as knowingly, and willfully executes or attempts to execute a scheme. Abuse is defined in terms of acts that are inconsistent with sound medial or business practice. Abuse is an unintentional practice that directly or indirectly results in an overpayment to the healthcare provider. Abuse is similar to fraud, the difference is that anyone investigating the “act” cannot establish if the act was committed knowingly, willfully, and intentionally. The term “intentional” is extremely important in defining abuse, fraud, ethical or unethical action (Rudman, 2009),
Healthcare fraud is committed when a dishonest provider or consumer intentionally submits or causes someone else to submit false or misleading information for use in determining the amount of healthcare benefits payable (Pozgar & Santucci, 2016, pg. 104-105).
Examples of fraud and abuse in healthcare range from:
Intentional misrepresentation of services that result in higher payments
Billing of unperformed services
The deliberate delivery of unnecessary and inappropriate services for the express purpose of receiving the payment
Inflating Insurance Claim,
Fraudulent Billing,
Pharmacist submitting false drug claims
Physician billing for services not rendered
Fraudulent billing for laboratory tests
The way that the compliance committee helps to monitor and prevent fraud and abuse in the health care industry start by implementing comprehensive compliance programs by having to take a look at the program and see how it is designed, how is it structured, and is it a real compliance program being practice. This will allow investigators, auditors, administrator do their jobs.
References:
Pozgar, G.D. & Santucci, N.M. (2016). Legal Aspects of Health Care Administration (12th ed.). Burlington, MA: Jones & Bartlett Learning.
