Dealing with Fraud

traffic with phvirtuosoy health C atomic get 18 Policy, jurisprudence, and morality HSA 515 March 09, 2013 Dealing with shammer Obstetric wellness bursting charge centers are a study source for providing charge to millions of women round the country and a branch of medicine that involves maternal quality and child turn in. Studies of pathologic and physiologic functions of the female reproductive battleground are withal a part of obstetric forethought. Physicians in this field commonly referred to as OB/GYNs and foreboding for the mother and fetus during pregnancy. As honcho Nursing Officer of one of the reads largest Obstetric Health Facilities countless women are set at this center.The lag is fully aware of the mission, vision, policies, and procedures that confound a huge impact in the community. Women depose on the compassionate and attention ask ind from the particular(a) physicians on round. Unfortunately, the type of wish delivered and the service the hospital is responsible for providing, word of machinationulent manners have been describe and mustiness(prenominal) be addressed. As United States wellness care cost sojourns to rise, people depend upon in private funded wellness send offs and millions are still uninsured repayable to funding by c all told forth and federal authorities.The major government sponsored health care plans are Medicare and Medicaid programs. two programs make up a large fortune of government spending. One key reason for wage hike costs has been the enormous degree of fraud act against government health care programs. Although billions have been undefendable due to informants of qui tammymymy, additional monies anticipate undetected. Ultimately, health care fraud used as a misleading means to profit from health care agreements by dint of the federal government and the reason the United States government activity Accounting Office has categorized Medicare and Medicaid as tough p rograms. Various sources evaluate the effect of qui tam in health care organizations and refer to the 1986 ludicrous introduce Act the hard-hittingness. The term whistleblowing recognized by victuals in the False Claims Act and authorizes cases be brought to the government on behalf of the United States to share in the determiney efforts. The Informers Act or make better known as The Qui tam Statue is from the Latin wording qui tam pro domino rege quam pro seipse, kernel he who as much for the king as for himself, depicted during the civil war and focused on ending dishonest suppliers to the union military.Therefore, fraud investigation, and judicial operation became easier for the government. The history behind qui tam statue and instantlys use provides an to a lower placestanding to the term whistleblower and for an individual with past or present cognition of fraud on the federal government to recover damages and impose penalties, (Cruise, n. d. ). Fraudulent beha vior or health care fraud affects health care organizations. Several ways businesses and individuals have defrauded, and continue to defraud, federal, and state government health care programs.Examples of fraudulent behavior include No Services Non-submission of cites for diagnostic tests, discourses, devices, or pharmaceuticals go that were never rendered. Non Existence Involves submitting a claim for the services previously mentioned and provided to long-sufferings that do not make it or never received service. Also an period billed for in the claim. Anti-Kickback decree bans any offer, payment, collection or response of money, property or hire to persuade or reward longanimous of referrals or health care services funded by a government health care program, including Medicare or Medicaid.These are improper payments and come in several unalike forms, includes but not limited to referral fees, finders fees, productivity bonuses, research grants, unreasonable compensati on, and free or discounted travel or entertainment. The offer, payment, solicitation or receipt of any such monies or remuneration ignore be a violation of the national Anti-Kickback statute, 42 USC 1328-7b(b), the Federal False Claims Act, various other federal, state laws, and regulations, (Pietragallo, Gordon, Alfano, Bosick, and Raspanti, LLC, 2013).These are just a small number of fraudulent activities currently affecting health care organizations. Qui tam has been an effective force in combating fraud. The judge Department continues to recover record amount of judgments and settlements, only, qui tam cases exist in a variety of health care organizations. Processing and payment errors of Medicaid and Medicare patients may step up to be simple mistakes and not by checkup professionals attempting to take advantage of the system, but individuals intent on abusing the system particularly, with working nowledge of how and when the government pays Medicare and Medicaid claims. Also in some cases fraud affects the people with these programs and liability occurs for co-payments and contributes to excessive government spending. Other examples of qui tam cases include speculative pricing/false negotiation reflects price adjustments by submitting false data and pricing to the government to receive an inflated amount according to the contract price. Mischarging one of the more widespread frauds used to submit claims for products or services never provided or rendered.Product/service electrical switch A product is certified that does not represent specifications or submitting a product for government cheers then substituting the merchandise with another of poorer quality. False certification benefit entitlement documents are falsely certified. education submitted to the government has been adjusted for price supports or mortgage guarantees, according to the source more than half of qui tam recoveries have involved health care fraud, qui tam lawsuits fil ed have been successful against defense contractors and other companies, ( ace Law, 2008).Various federal and state strikements must be satisfactory by the health rapidity prior to admission. For example, pre-admission evaluations for Medicaid patients require prior determination for eligibility. A full patient assessment exit determine a plan of care. The prescribed care plan is prepared by the be physician and registered nurse. Other hospital rung get out get involved with the patients care if necessary. The care plan is updated on a every quarter basis, or more frequently if the patients condition changes.Other requirements for Medicare and Medicaid patients must be met to begin with admission to determine suitable environment and to discover patients rights after admission speckle receiving checkup examination care. Procedures for admission into a health adroitness for Medicare and Medicaid referrals must understand and postdate with the laws that govern these proc edures. The Anti-Kickback Statute (AKS) enacted by Congress delivers criminal penalties for the payment of fees designed to persuade or reward medical referrals for give-and-take covered by Medicare and Medicaid.The AKS is extensive and includes discounts for physician referrals. liability is a major concern under the Anti-Kickback Statue unless procedures authorize within the law. Another regulation that limits physician self-referrals for Medicare and Medicaid patients is The plain Law. Hospitals or health care providers are proscribe from receiving payments or kickbacks after improper direction Medicare for selected equipment or services. Ultimately, claims cannot be submitted by physicians for items or services because of their financial relationship with the health care providers.The Stark Law passed because of inappropriate financial relationships between doctors and health care providers and the professional judgment of doctors with regard to whether items or services a re medically necessary, safe, or effective also reduce probable overpayments by Medicare for uncertain services, (The Qui tam-o-shanter Team, 2012). The next stage is for physicians and nurses review the quest conditions for patient referrals. 1) Services must be personally referred by the attending physician. 2) Referrals are to a physician of the alike root or practice. ) Any individual supervise by the referring physician in the hospital or physician that works part-time in the facility and is part of a group practice must comply with all coverage and payment rules regarding Medicare and Medicaid patients. 4) tolerant billing is by the physician performing or supervising the care and treatment of the patient. 5) Regarding a group practice, attending physician under the group must be a member with an assigned billing number different from physicians employed with the health facility. ) trine party billing companies representing the physician(s) ordain also be assigned a bil ling number. These companies have to comply with Medicare requirements. The task of evaluating referral arrangements by physicians will be challenging, however financial provisions involving physicians can be analyze using the conditions outlined. The Chief Nursing Officer will receive a monthly report of Medicare and Medicaid referrals. Non- obligingness will result in immediate termination from the health facility. Discussing fraud and villainy the health industry continues to tolerate billions.Fraud can range from performing unnecessary medical procedures for insurance gains, to altering patient teaching and illegitimately billing for services not rendered. Also accept kickbacks for patient referrals, and promoting drugs without dominance. These incidents affect the economy and are in all likelihood hazards to the health and safety of patients. An example is medical information illegally altered may receive haywire treatment or realize existing health benefits are exhaust ed. Either way another alternate(a) for entry can address these issues.A method of enforcement created by the office of the Inspector General (OIG) identified as a Corporate rightfulness pact to alter health care quality and promote residence to health care guidelines. The term Integrity Agreement focuses on physicians according to one source. Establishing OIG 1976 to imposed exploit against widespread fraud and abuse in Federal health care programs. These efforts developed a cooperative use of enforcement tools as monetary penalties and exclusions. Corporate Integrity Agreements implemented by the OIG to redeem health care providers under the program to bend exclusions.Implementing a CIA will be challenging and somewhat complex, especially for birth and reproduction. The sterilization process, wrongful birth, and wrongful life are areas of interest, and the CIA will have major impact. Physicians play a major role due to misconception by antepartum testing, genetic testing, and laboratories that failed to provide these services. Sterilization falls under reproduction and birth is another area likely for fraudulent behavior from the side effects patients go through and were not informed by the attending physician.Nevertheless, to address current fraud behaviors and block future incidents among physicians, nurses, and medical staff it is necessary to develop strategies to check into ethical and moral business practices through compliance of various laws that will reduce any jeopardize of legal liability. Although the CIA program contains various features, after vigilant review and collaboration among executive staff the following requirements will accommodate the needs and requirements that will apologize incidents of fraud by Developing written policies and standardsInstituting a confidential revealing program Employing a compliance officer or a compliance de lay outation Implementing an employee training program Restricting employment of inel igible persons Report overpayments, fraudulent behaviors, and ongoing investigations/legal legal proceeding Implementation reports are provided annually to the regulatory agency, (Sable, 2013). These requirements should prevent future fraud misconduct by ensuring inherent actions and mitigating methods are in place. In conjunction with fraud and abuse is protecting patient information and omplying by all applicable laws. Accessing patient information considered a major subject for health organizations to comply with the Health Insurance Portability and Accountability Act (HIPPA) laws. Patient medical records are vital for treatment and must remain confidential within the federal and state laws. Without authorization the patient Privacy Rules are in violation. The responsibleness of Chief Nursing Officer ensures the medical staff training and knowledgeable of health centers policies and procedures to remain in compliance with HIPPA.Often areas overlooked whether inadvertent or in tentional and certain information is discussed or discarded documents. Routine conversation among staff would be limited to specific areas where patient information cannot be disclosed. Public areas such as elevators, hallways, or postponement areas are strictly off limits. Many measure patients are in surgery or receiving treatment for an illness, family members are waiting for results and often physicians will put up with them in public areas to discuss sensitive information not realizing the conversation can be overheard by others. This is just one example of a disclosure violation.Also what may sound insignificant represents another action that can lead to breach of information by patient documents thrown in a grouch can that must be shredded to avoid public view. The plan is simple to comply with all necessary laws extensive training provided to the entire staff is the beginning. One-on-one and group meetings held on a quarterly basis as a tool to prevent abuse and fraudule nt behavior. Patient sensitivity is demand in meeting the goals of health center. Laws provide direction for dealing with fraud cases or any unethical or moral decisions made.To eliminate fraud and abuse continued pressure on the government to establish tougher policies in the delivery of medical and health care services. Additional funding for government enforcement agencies will put more pressure on physicians to act responsibly. As physicians become more aware of this fact, he or she should continue to take steps, such as implementing a compliance plan, to ensure the services provided reflect effective documentation for claims of payment. Until doctors, nurses, and other medical staff institute ethical and moral standards, fraud, and abuse will continue to a problem for health organizations. ReferencesFraud and Qui Tam Cases. (2008). Retrieved from http//www. lawyershop. com health care Fraud and Qui Tam Suits. (2008). Retrieved from http//www. lawyershop. com Pietragallo, Gord on, Alfano, Bosick, and Raspanti, LLC. (2013). Health Care Fraud and False Claims. Retrieved from http//www. falseclaimsact. com Cruise, P. L. (n. d. ). Deregulating Health Care Ethics Education. Retrieved from http//www. spaef. com/article Sable, L. (2013). Negotiating Corporate Integrity Agreements. Retrieved from http//www. franchiselawsolutions. com The Qui Tam Team. (2012). Types of Qui Tam Cases. Retrieved from http//www. quitamteam. com