The Role Of Fraud In Healthcare

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Healthcare fraud what is it and who’s impacted by it? Healthcare fraud is a crime that has made a huge financial impact on the private and public sectors health care payment systems, The fraud occurs when someone falsifies a fact related to health care services to obtain or increase payment from a health plan or the government. It also occurs when someone falsifies details in delivery of healthcare services or materials (Kongstvedt, P 2012). Healthcare fraud has cause and continues to be a major economic drain on the healthcare system. It does not matter if it’s an employer sponsored health care plan or individual plan when healthcare fraud is committed all consumers are subjected to higher monthly premiums, increase out of pocket
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• Stark Law – prohibits physicians from making self-referrals or from referring patients to other entities of the physician or immediate family that has a financial relationship.
• Federal Food, Drug and Cosmetic Act – makes it unlawful to introduce an adulterated or misbranded pharmaceutical product or device (King, K.2012).
Examples of the most common forms of provider and member fraud is a follow:
• Billing for services that were never render by using other member’s data or by falsifying claims with charges for procedures or services that did not take place.
• Up coding medical services or procedures which means billing for services and procedures that cost more but were not performed
• Up coding for medical equipment or supplies which also means billing for more costly supplies than what was distributed to the patient.
• Unbundling, billing each phase of the procedure like it was a single procedure.
• Charging patient’s a co-payment for services that were prepaid or paid in full.
• Receiving kickbacks for patient
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Whether the fraud is an accident due to carelessness or a scam out by a deceitful worker, hospice and homecare owners must take provisions to legally and economically protect their business. The process of protecting themselves, their agencies , and their patients begins and ends with their staffs. From doctors to bookkeepers to administrators, healthcare fraud and abuse can be supported by anyone at any level of the company.
The below is a few measures that an organization can take to help prevent the fraud:
• Implement internal controls – in order for an organization to operate efficiently the internal controls need to be in compliance with the laws and regulations. Vital healthcare fraud and abuse guidelines and measures include defining access and authorization controls, as well as separating duties to reduce opportunities for fraud to occur (Colling, T 2011).
• Employ honest people: make sure background checks are performed on all staff members. It’s always a plus to verify information provided such as education, employment, and criminal
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