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Fraud and Abuse and the Law

Eunice

Fraud and Abuse and the Law

Sophisticated frauds and abusers are forces that have remained potential threats to the credibility and sustainability of health systems, resulting in millions of dollars drained yearly. This handbook will outline the main issues connected with healthcare fraud and abuse and recommendations concerning detecting, avoiding, and reporting. Besides, analyzing five primary legal mandates that address healthcare fraud and abuse will highlight the legal requirements in the compliance processes.

Categories of Health Care Fraud and Abuse and Recommendations

Billing Fraud

Billing fraud refers to the ability to make and submit claims that were not rendered out or attempt to make statements that a specific service was provided. At the same time, it was offered under a different description. Measures to retain and prevent billing fraud include bill assessment, which can be done consistently, and data processing technology, which can highlight outrageous charges. Deterrence can be brought about by enhancing staff awareness by training them to follow correct billing standards and penalties to expect in case of fraud (Kagias et al., 2024). Reporting mechanisms should comprise whistleblower lines or applications through which workers can submit concerns about suspicious billing actions without being vindictively penalized. Reporting systems should be such that they are anonymous and readily available and that employees are not threatened.

Kickbacks and Referral Abuse

Both kickbacks and referral abuse present some monetary gains using patient referrals and are prohibited by the Anti-Kickback Statute. Kickback schemes will be detected better, and referral sources, compensation contracts, and regular compliance checks will enhance civil society’s ability to do so. Also, the regularly implemented use of data analytics to look for abnormal referral patterns and third-party audits of referral relationships can come across additional kickback relations that are malicious. Red flags such as overutilizing certain services or a high concentration of referrals to specific providers should also prompt further investigation. To minimize this kind of fraudulent activity, organizations should organize seminars that explain whistleblowing laws concerning kickbacks and ensure that an ethical policy prevails in the organizational culture (El-adaway & Jennings, 2022). There is a need for a reporting system for employees to report suspected kickback arrangements to enhance organizational accountability.

Upcoding

Upcoding refers to billing for a more expensive service than was provided, inflating reimbursement claims. Audits that compare charges to the medical record and identify unusual charge patterns and charges that do not correspond to the services offered are suggested to detect upcoding. Further, billing software can be improved to alert of such manipulation by comparing it with the standard time available for treatment and procedures. These same audits also help detect anyone attempting to engage in fraudulent coding in high-revenue departments, which may be found by conducting occasional random checks. Deterrence measures involve regular staff training of coders and staff knowledge of coding rules, regulations, or standards on disciplinary action against coders (Kuo et al., 2021). For reporting, organizations must implement compliance hotlines, which the employees use anonymously to report any suspected upcoding cases.

Unnecessary Services

Unnecessary services are services offered to patients that are not required for medical needs; that is, services offered for business purposes to produce revenues. The detection can be done through observation of patients’ treatment process and outcomes, searching for cases when some organizations might be providing services that are not needed, as well as through observing records and documents. To discourage providers from performing or recommending unnecessary services, authorities should disseminate and circulate a treatment guide and information on best treatment practices (Dyann Matson-Koffman et al., 2023). An organizational reporting system should be comprised of questionnaires that ask the patients for their opinions as to whether the services that the patient was receiving were necessary to eliminate the chances of overreliance on such services.

False Claims

False claims involve submitting inaccurate or misleading information in an attempt to be paid by Medicare or Medicaid. Among the detection measures are compliance audits and programs highlighting discrepancies between what was said about a patient and how the patient is. Deterrence may be complemented through staff sensitization against the risk of working on fraudulent claims and the legal and administrative risk of filing such claims (Wu et al., 2023). To encourage reporting, healthcare organizations should have a means through which the visitors can complain without compromising their jobs by providing methods through which employees can report false claims.

Health Care Fraud and Abuse Laws

False Claims Act (FCA)

One of the most significant federal anti-fraud statutes is the False Claims Act (FCA),  which provides liability to any person who has made or used false claims to obtain payment for Government property or services or Government contracts. It allows members of the public, referred to as whistleblowers, to sue the government by providing incentives to fraud reporters. It’s very effective in refunding billions of dollars to federal governments through penalties on fraudulent billing. However, some voices criticize them because they posit they may lead to over-litigations, encouraging unmerited claims. Its improvement has incorporated changes and the escalation of funds for investigating bureaus to have better measures to fight forgery as a feature of the FCA. The FCA greatly enhances accountability and transparency, particularly in the health sector, since it discourages fraud in the healthcare system.

Anti-Kickback Statute (AKS)

The Anti-Kickback Statute (AKS)  prohibits receiving, soliciting, or requesting payment for referrals for services reimbursable through a federal healthcare program or for the purchase of and for recommending such services. Executing the Anti-Kickback Statute is crucial because it tackles legal and ethical aspects that relate to financial motivation, threats in the delivery of patient-related services, and costs associated with treatments that might be unnecessary. It has both civil and criminal penalties in corporate, and therefore, it is a forceful weapon for prosecuting healthcare fraud. However, the Statute is a compliance problem for real business action, as the healthcare suppliers might need help with the law as it is with rules. New rules have emerged from the Department of Health and Human Services regarding acceptable activity and safe harbors for specific structures. All in all, the AKS remains vital in protecting healthcare referrals and ensuring patient safety.

Stark Law

Stark Law, also called the Physician Self-Referral Law, prohibits physicians’ referral of patients to other entities about financial interest regarding Medicare and Medicaid services. This law is an anti-kickback measure directed at arrangements that result in extra testing, treatment, and federal funds protecting the patients. Stark Law, which was developed to provide for civil actions about a particular kind of business relation between parties, has penalties for violation principally owing to its role in upholding ethical practice in medical practice. However, as many healthcare providers in the study pointed out, they required clarification on the specific law and what constitutes a financial relationship. It is, therefore, essential to know that Stark Law has been revised in recent times to reduce the complexities and level of strain exerted on the provider while simultaneously eradicating all measures of misuse where the need arises. Overall, Stark Law is one of the essential tools for protecting the healthcare system from self-referral corruption.

Health Insurance Portability and Accountability Act (HIPAA)

The  HIPAA principally focuses on patient privacy and the security of health information, but it also includes provisions that combat healthcare fraud and abuse. Due to HIPAA, plans to safeguard health data are required, lowering identification theft and fraudulent claims (Basil et al., 2022). Also, regarding penalties for violation of regulations related to privacy, there is an enhancement of legal repercussions that force healthcare providers to be answerable to the stipulated laws. However, the enforcement of HIPAA has had its limitations, especially in the face of relatively new advances such as digital health records and telehealth services; the fight against and prevention of data breaches necessitates continued modification of security measures. Critics also say that much of HIPAA is implemented in a system of complicated rules, which could make it difficult for these smaller providers to offer services that people need and to do so without sacrificing their bottom line. However, HIPAA remains one of the significant benchmarks of patient data safeguarding and maintaining the healthcare industry’s credibility against fraudulent activities.

Civil Monetary Penalties Law (CMPL)

Civil monetary penalties enforcement authority is granted to the Department of Health and Human Services through the Civil Monetary Penalties Law (CMPL) for several types of fraud concerning Medicare and Medicaid. This law allows observing many fraudulent behaviors with the possibility of their flexible control, such as overcharging and kickbacks. First, the CMPL acts as a discouragement for fraudsters while, at the same time, providing a way to regain lost federal funds, thus contributing to the overall integrity of federal healthcare programs. However, it is effective. It is also hampered by the various problems accompanying the difficult task of proving fraud and the time-consuming investigations accompanying a case. Recent initiatives have aimed to streamline the enforcement process and enhance collaboration between federal and state agencies.

Conclusion

Therefore, efforts to counteract healthcare fraud and abuse must employ profound categories of diagnosing the issues, a better mechanism to enhance the detection and reporting of the scourge, and strict legal compliance. By creating a compliance and accountability culture at AIU Regional Hospital, the organization has a well-developed approach to fighting fraud and abuse and maintaining the highest level of healthcare services. Many of the suggested recommendations and evaluations of fraud and abuse laws guide efficient training and compliance. At long last, the discussed approach to combating healthcare fraud and abuse is crucial for promoting patient and public interests.

References

Basil, N., Ambe, S., Ekhator, C., & Fonkem, E. (2022). Health records database and inherent security concerns: A review of the literature. Cureus, 14(10). https://doi.org/10.7759/cureus.30168

Dyann Matson-Koffman, Robinson, S., Priya Jakhmola, Fochtmann, L. J., Willett, D. L., Lubin, I. M., Burton, M. M., Tailor, A., Pitts, D. L., Casey, D. E., Opelka, F. G., Mullins, R., Elder, R., & Michaels, M. (2023). An Integrated Process for Co-Developing and Implementing Written and Computable Clinical Practice Guidelines. American Journal of Medical Quality, 38(5S), S12–S34. https://doi.org/10.1097/jmq.0000000000000137

El-adaway, I. H., & Jennings, M. (2022). Professional and Organizational Leadership Role in Ethics Management: Avoiding Reliance on Ethical Codification and Nurturing Ethical Culture. Science and Engineering Ethics, 28(4). https://doi.org/10.1007/s11948-022-00385-2

Kagias, P., Garefalakis, A., Passas, I., Kyriakogkonas, P., & Sariannidis, N. (2024). Whistleblowing Based on the Three Lines Model. Administrative Sciences, 14(5), 83. https://doi.org/10.3390/admsci14050083

Kuo, K.-M., Talley, P. C., & Lin, D.-Y. M. (2021). Hospital Staff’s Adherence to Information Security Policy: A Quest for the Antecedents of Deterrence Variables. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 58, 004695802110295. https://doi.org/10.1177/00469580211029599

Wu, F., Cao, J., & Zhang, X. (2023). Do non-executive employees matter in curbing corporate financial fraud? Journal of Business Research, 163, 113922. https://doi.org/10.1016/j.jbusres.2023.113922

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Question 

You will create this assignment following the Assignment Detail instructions below.

Review the tutorial How to Submit an Individual Project.

Assignment Details

This Individual Project (IP) builds upon your work in Units 1, 2, and 3.

As Director of Risk Management of AIU Regional Hospital, you hire a new Director of the Compliance Department. You have requested that your new director prepare the section in the handbook on annual compliance training outlining the standard categories of fraud and abuse, laws, and recommendations to detect, deter, and report fraud and abuse.

Identify and address the significant categories of health care fraud and abuse, providing recommendations (providing references for each) to detect, deter, and report each major category, and evaluate 5 health care fraud and abuse laws.

Deliverable Requirements: The brochure for the annual compliance training session should be at least 5 pages long. Be sure to cite at least 5 sources using APA properly; include references and in-text citations. Title and references pages do not count as part of the 5 pages.

Fraud and Abuse and the Law

Fraud and Abuse and the Law

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