459.1

        In commenting on the policies that your classmates have presented below, describe the relationship between the political environment and health care decision making.  Why are they so interconnected?Minimum 100 words

1. Strong-The example of the policy I looked at from an external healthcare organization is about Medicare fraud.  Medicare fraud is a profoundly impacting healthcare problem.  The goal of all profit facilities healthcare is to generate funds the less that is spent; the more that is brought in is better to ensure that all billing processes are handled fairly and honestly.  Fraud means paying for services that have not been reported, have not provided, or have not been rendered by the customer. Fraudulent billing defrauds government and insurance companies and is illegal and punishable by the law court.

Fraudulent billing to Medicare and any insurance entity is considered in terms of fines and jail time. This act of fraudulent activity can also result in the facility being excluded from participating in federal healthcare programs and insurance companies, or even punishable by loss of their license.  Some of the federal laws governing Medicare fraud and abuse include–Anti-Kickback statute (AKS), False Claims Act (FCA), Stark Law, Social Security Act.

These law enforcement agencies explain the criminal and civilian remedies the government may enact.

Most operations have zero tolerance for fraud.  Billers must comply with stringent laws and regulations that they must follow: audits and random tests must be in full compliance.  They must have a posted hotline phone number open for all member of staff to call if they are reporting fraud misconduct.  A non-relation policy published on the premises of the services. Documentation on strong point of service for all billing records.  As well as ongoing continuing education or CEC credits according to the latest rules and regulations our government warrants.

When fraud is reported, the customer is promptly informed after reporting. Corrective steps are recommended. A plan is formed by an organization and facility to enable the facility to operate effectively on the requirements and standards of the Medicare policy.

2.Masters-The example of a policy or guideline from an external source to healthcare that I have chosen comes from the Infectious Disease Society of America. The IDSA gives guidelines for physicians as well as patients in reference to their healthcare an also specific clinical cases. (idsociety.org). Since we have a global pandemic here in the United States and around the world today, gudelines through the IDSA hav a strong impact on the delivery of healthcare given to patients in this crisis. The IDSA has guidleines for other infecious diseases, but with COVID -19 they are constantly being updated. With the fast pace changes, there are challenges that the healthcare organzations face wth keeping up with challenges and trying to save lives. New drugs are being introduced such as the highly publicized drug, hydroxychloroquine and azithromycin(z-pack). Healthcare delivery is a primary function and quality of care of any healthcare organization. According to our textbook readings planning is making a decision now and setting a course of action in place for the forseeable future. (Liebler, & McConnell, 2017). The healthcare industry have a great deal to learn from this pandemic and can use data and research to plan now for such a outbreak if it were to happen again. 

Since this is a constant changing turn of events , there will be a need for a permenant task force to be in place as well as continued research to prevent other pandemics from happening. Coninuous planning will be needed througout this health crisis and beyond in order for healthcare organizations to operate efficently and have proper planning in place.