Medicare Billing Violations

Today, a medical assistant has asked to speak privately with me, the office manager, about a matter that she is greatly concerned about. She makes an accusation of fraudulent billing that is against one of the medical doctors on staff. The medical assistant alleges that she has noticed recently in the past few months that this particular doctor has repeatedly been upcoding higher evaluation appointment code descriptions for all of his Medicare patients’ appointments. She believes that these visits should have been listed with lower medical description codes for billing purposes.

One of the most popular health plans that people use is Medicare. One of the reasons why this is so is because it is public and goes towards making health coverage more possible. One payment plan states that people pay $104.90 monthly, with a $147 dollar deductible. Another payment plan under Medicare states that one has to pay $407 dollars monthly at the most. ("Medicare", 2015). The third payment plan varies and is dependent on the plan that they are using. Because the medical industry works to become more and more accurate in all medical terms, it is necessary for patients being just as accurate when applying (2015). This way, clients will get just the health plan they need.

There are many different factors Medicare has impacted the healthcare system. For starters, when they started Medicare up in 1965 there were a lot of the elderly without insurance. Unfortunately, this was due to the cost of insurance, and the coverage. Which in fact, having no insurance left our elderly vulnerable to chronic illness and other illness that could have been avoided. “Since the amendment of Social Security created Medicare, in 1965 only about 1% of elderly Americans are without health insurance.”(Michael Lewis)

Unfortunately HIPAA violations happen every year in our country. In fact, a situation happened in a New York-Presbyterian Hospital and Columbia University Medical Center on May 7th 2010. The HIPAA violation happened after the electronic health records of 6,800 patients ended up on Google for the world to see. The United States Department of Health and Human Services (HHS) who are responsible for HIPAA enforcement laws deeply investigated this case. It was discovered that a Columbia University physician who developed applications for New York-Presbyterian Hospital and Columbia University, attempted to deactivate a personally owned computer server on the network containing electronic protected health information (ePHI). Due to lack of technical

Medicare was initially formed as a health insurance program to provide aid in medical expenses for the elderly. President Lyndon B. Johnson influenced the path of these Medicare and Medicaid programs during his term as president in 1965. During the time that Ronald Reagan was president, new Medicare cost control approaches for health care providers emerged, which aided determining reasonable charges for the services provided and payment options. Medicare and Medicaid were the establishment of a mainstream model of federal medical assistance to people who are unable to secure it for themselves. Over time, many different policies have been endorsed to provide access to health care for specific groups who may be unable to pay for their own medical

They must ensure that they are providing adequate services to patients and at the same time ensuring that insurance companies are getting paid (Saint Joseph’s University, 2011, Para 6). Along with that they must secure that they are getting paid. Furthermore, physician moral and ethics are challenged as well; Thus, causing them to rethink how they take on their responsibilities as a medical care provider by trying to keep patients best interest, insurance companies interest and their own interests. This conflict with trying to meet the needs of several different stakeholders causes strain on the physician because they must walk fine line to please each. While trying to please a specific stakeholder another holder could be compromised.

According to Furrow et al. (2013), when healthcare organizations and providers fail to comply with HIPAA rules it can result in civil and criminal penalties. The AARA created a structure of four tiers of civil penalties for HIPAA violations, which the Secretary of the DHHS has discretion in determining the penalty. For example, tier 1 penalties apply to violations due to reasonable cause and not due to willful neglect. In other words, the healthcare organization is unaware of the HIPAA violation. In this situation, the minimum penalty is $100 per violation with an annual maximum of $25,000 for repeat violations (Furrow et al., 2013). Tier 2 penalties apply to violations for reasonable cause, but not willful neglect. In this situation,

Health Insurance Portability and Accountability Act established in 1996 sets standards for health care information. These laws protect patient’s sensitive health information. The purpose of this discussion is to review a former UCLA employee’s HIPAA violation. Additionally, HIPAA laws and penalties for violation up for examination. Ending this discussion with the possible charges that the employee may receive.

I feel that these doctors are feeling pressure to prescribe pain medications in order to increase patients scores and in return improve reimbursement for their units. This is contributing to the increase of opioid abuse that is already prevalent in this nation. This needs to be taken into consideration

Hello, in this white paper I am going to tell you why we need to cut government spending. First, let me show you this chart for total government spending.

Drug companies spend hundreds of millions of dollars a year to make sure doctors keep writing prescriptions, and since direct kickbacks to doctors are illegal, drug companies and medical supply firms have found increasingly creative ways to put money in the doctors’ pockets. Drug and medical device companies spend hundreds of millions of dollars per year to influence medical providers. Influence comes in the form of large commissions for doing speeches on behalf of, and written by, the medical company, first class travel and all expense paid trips to exotic destinations, all for the sole reason of attending drug companies’ conferences where the doctor will sign up as a guest speaker or as a consultant. 94% of doctors have some affiliation with a drug company or medical device company. In 2014, a sunshine law takes effect which will require companies to make public all the money they funnel to medical providers; we should finally be able to see how many millions have gone to the doctors and others (George Knapp, 2013).

Which under the current design addresses long- term care for a limited amount of time, such as for rehabilitation purposes. These services cannot be received outside of a Medicare-approved facility, which means the person cannot reside in their home and receive the long-term care assistance under the current system. Therefore, we propose to amend this portion of the program to extend the funding for long-term care to include home care. Which consist of the relatives receiving monetary compensation for their care. Under the current policy, 41% of the Medicare budget of $50,000,000,000 is being advocated this particular area. We propose taking 8% of this budget and applying it towards long term home based care. Moreover, we are advocating for home based funds to be obtained by amending Medicare part B, which under the current policy only covers extended care in a Medicare-approved establishment. We do not propose totally doing away with the present system because our policy does recognize the need for these facilities to continue to meet individual needs that cannot be met in a home based environment. The proposal adds the additional component of supplemental income for a home-based long-term care of, which covers

Billing 1 Week 2 DB Discuss the importance of knowing the processes and procedures used for receiving payment for services rendered under the contract provisions. It’s extremely important to understand both the process and procedures of securing payment for medical services under a managed care contract agreement. The process for receiving payment for services begins when the patient makes their initial appointment with a provider.

The existing law also has the ability, to give the board powers to put him or her on probation depending on the conditions. Therefore, information obtained from the MBC, in fiscal year 2015-2016, received 8,679 complaints against physicians and surgeons and unlicensed individuals alleged to be practicing medicine without a license. These complaints include allegations including excessive prescribing, gross negligence/incompetence, licensee self-abuse of drugs or alcohol, convictions of a crime and general unprofessional

How would you feel if you discovered that doctors were pushing flu vaccinations on patients just for financial reasons? That, along with many other, is one good point Claire Dowskin brings up in her article “The Truth Behind Flu Shot Mandates for Healthcare Workers”. In some hospitals flu vaccination funding for employees is out of the funding, and in some hospitals, will fire, or not hire, people if they have not, or refuse to receive a flu vaccination, wearing a mask is not even acceptable. Seeing how strict and forceful some hospitals are about flu vaccines would make one think they act this way for a payout for the vaccine distributers. Another way to look at this is how unethical mandatory vaccines are.