Case Study – Healthcare Quality
Quality Issues
Three fraud quality issues emerged from the case in Dr. Antebi’s billing activities. The patients who visited the hospital for medical attention noted how strange Dr. Antebi offered services to them. The investigation team interrogated some patients concerning the quality of services they obtained in the facility and the three quality issues noted. Firstly, the doctor only attended to them briefly for a few minutes, and often, he did not perform any diagnostic during their visit. Secondly, no medical equipment was used while conducting medical examinations, and hospital rooms were without essential check-up tables for medical procedures. Lastly, it was indicated that medical practitioners attended to the patients outside the required clinical rooms.
Patients deserve better services than what they were offered, like in this case. The billed money of more than twenty-four million to healthcare and other cover corporations was more than what the doctors offered to the patients. Healthcare facilities should also upgrade their medical services by providing enough and proper medical equipment for medical examinations.
Violations
Medical Billing Fraud
This act occurs when one or the healthcare facility personnel bills for services not offered to patients or for services not performed to completion (Koreff et al., 2021). In this case, Dr. Antebi allegedly billed for the services he and the healthcare did not offer. According to the study, he even billed when he was not present in the office and when travelling out of the country.
Wire Fraud
This is an act of trying to commit a crime by transferring funds by electronic means (Gupta et al., 2021). Insurance companies provide finances for patients via billing by various healthcare facilities. Dr. Antebi billed the companies and government electronically, thus committing this fraud. In the USA, wire fraud is punishable, and the penalty for this fraud is to serve 20 20-year jail term and a fine amounting to $250,000.
Mail Fraud
This fraud is close to wire fraud, where people attempt to obtain money via electronic means or email (Koreff et al., 2021). This is a federal crime in the USA, and parties knowingly involved in it are charged. Dr. Antebi billed using email and other electronic means to obtain money he did not deserve.
Application of Case Study as a Training Tool
Many case studies are often used as training tools in different organizations (Koreff et al., 2021). The case of Dr. Antebi, a doctor charged with committing billing, mail, and wire fraud, can also be used as a training tool in our healthcare organization, Medicare and Medicaid Services, and the Department of Justice (DOJ) information on quality and fraudulent billing. The case can help my healthcare organization monitor how billing is conducted daily. The study indicates that billing processes were done illegally when health providers billed an amount of money that exceeded the services offered. Therefore, this case is explicit on what is happening in healthcare facilities. This case will inform the organization of the importance of complying with the billing regulations in healthcare. This case can also inform the personnel in the organization of the expected penalties if one becomes a victim. Also, according to the case, the investigations done by relevant authorities like the Department of Health and Human Services Office of Inspector General will ensure providers offer quality services to patients and prompt the facility to purchase and organize better medical equipment for diagnostics and examinations.
References
Gupta, R. Y., Mudigonda, S. S., & Baruah, P. K. (2021). A Comparative Study of Using Various Machine Learning and Deep Learning-Based Fraud Detection Models For Universal Health Coverage Schemes. International Journal of Engineering Trends and Technology, 69(3), 96–102. https://doi.org/10.14445/22315381/IJETT-V69I3P216
Koreff, J., Weisner, M., & Sutton, S. G. (2021). Data analytics (ab) use in healthcare fraud audits. International Journal of Accounting Information Systems, 42, 100523. https://doi.org/10.1016/j.accinf.2021.100523
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Question 
Case Study – Healthcare Quality
Overview
To complete this case study, refer to this week’s readings for policy information required to analyze and make recommendations on this case.
As a healthcare quality fraud analyst, you are responsible for identifying root causes and providing recommendations in an action plan to ensure compliance with federal and state quality policies.
Instructions
Read the Department of Justice story, “South Jersey Doctor Charged in Health Care Fraud Billing Scheme.” Then, write a 1–2 page report in which you:
1. Summarize three quality issues in the case that resulted in fraudulent billing and coding.
2. Describe three violations stated in the case, including how the violations applied based on regulations.
3. Illustrate how this case could be used as a training tool for your organization. You may base your work on the Department of Health and Human Services Office of Inspector General (DHHS-OIG), the Center for Medicare and Medicaid Services (CMS), and the Department of Justice (DOJ) information on quality, fraudulent billing, and so on.