...EMR and Health Care Fraud The realization of the Electronic Medical Record (EMR) is one of the greatest technological health care achievements. However, this realization has brought about many additional concerns. Regarding EMR, some of these concerns include: billing for services not provided, misrepresenting dates/locations/providers of services, incorrect reporting of diagnoses or procedures, double billing, and upcoding. (Piper, 2013) Many of these issues did not just appear with the introduction of EMR, but there was a surge of billing fraud complaints--from patients and Medicare recipients. EMR implementation has changed the modern health world, but it does not come without its setbacks. “The $1,000 Pap Smear” EMR has been called out for its easy set-up for...
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...free to a percentage of the costs that the government finally get thus of the court case. The qui tam supplies have been used with increasing occurrence in current years to start court case against pharmaceutical producer for deception that these companies have supposedly committed against federal and state health care programs. This paper tries to clarify the effects that these whistleblower court case have had upon the health care industries. This paper also suggests traditions that the False Claims Act and government enforcement efforts could be rehabilitated in order to decrease both playful qui tam court case and require for such wide False Claims Act trial History of the Whistleblower Provisions of the False claims act The False Claims Act (“FCA”) is one of the strongest tackle the government possesses for fighting fraud adjacent to the United States. As the government may bring suit to improve sufferers from deception without collaboration from private people, the FCA also approve private people with non-civic information relating to the deception to bring suit on behalf of the government. These whistleblower (or “qui tam”) suits allow the applicant to get a proportion of the revival for the government, that proportion changeable depending upon whether or not the government itself interfere in the suit. By give power to private persons to start FCA court case and pledge them a part of the government’s revival, the government is capable to penalize...
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...Opportunity Perspective for Fraud 1 Running Header: OPPORTUNITY PERSPECTIVE FOR FRAUD Opportunity Perspective for Fraud Opportunity Perspective for Fraud 2 Health care fraud, categorized under white-collar crime, refers to the filing of false health claims to get a profit. This is done when corrupt and untruthful provider or member maliciously submits or makes someone else to file information that is misleading. There are many forms of such deceptive health care schemes where a health care practitioners and members are involved. The opportunity to commit frauds specifically in the healthcare in industry is considered to be looking any employee in the eye due to the ease of getting away with it. With the ethical and moral issues that have plagued the healthcare industry the commission of fraud by my healthcare workers is one of the most common. Too many cases of healthcare fraud had been done unnoticed and so many healthcare workers have become rich. While there are some fraudulent activities that have been caught, there are still many opportunities that present themselves for every healthcare worker and professional to challenge their ethics, morals, and values. One example of a health care fraud by a provider involves billing patients for services that were never rendered to them. Some doctors would send Medicare or Medicaid a bill for a clinical procedure...
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...television and newspaper stories nearly every day about all kinds of corporate schemes and scams. Behind every fraud is a person or a group of people who has taken what is not theirs to take. Some of those people intended to steal they just never thought they would get caught. Others were pulled into the original crime or some aspect of the cover-up and before they knew it they were labeled a co-conspirator. This study will examine the people behind the much publicized fraud scheme at HealthSouth. Some did not set out to commit white-collar crime but found themselves as defendants in criminal trials for fraud. In the HealthSouth case in observation, real life examples of people who were "just doing their job" but at some point crossed the line from law-abiding citizens to law-breaking villains. Seemingly small compromises in ethics and morality led to a full-scale commitment to fraud. Finally, we will conclude that nobody sets out in their career to end up in prison cleaning toilets and on the front page of the Wall Street Journal after they are arrested for fraud. At some point, though, many end up that way. A. Background of the Study The study all about the recent accounting scandal that were reported : “The HealthSouth Scandal of 2003” as the researcher has become interested in finding out what made some this issue to happen. B. Statement of the Problem This study all about the story of the recent accounting scandal that were reported: “The HealthSouth Scandal of 2003”...
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...professor wrote a revealing article about how Glaxo manipulates research evidence in medical journals. He gained this insight through internal company documents he had access to during a lawsuit. Bottom line? If you think corrupt and dishonest drug companies are being honest about vaccine safety, efficacy and adverse reactions, you have been deceived by their marketing and PR departments. Glaxo is pleading guilty and paying a criminal fine of $1 billion for misreporting efficacy data and failing to report adverse safety data from post marketing studies. ****************************************************************************************** Department of Justice Office of Public Affairs FOR IMMEDIATE RELEASE Monday, July 2, 2012 GlaxoSmithKline to Plead Guilty and Pay $3 Billion to Resolve Fraud Allegations and Failure to Report Safety Data Largest Health Care Fraud Settlement in U.S. History Global health care giant GlaxoSmithKline LLC (GSK) agreed to plead guilty and to pay $3 billion to resolve its criminal and civil liability arising from the company’s unlawful promotion...
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...Health Insurance Fraud By: WAHEED ALKHAMEES KHALED ALNAFEE Further Issues Hospital Administration PA 551 Master of Health and Hospital Administration (Parallel) King Saud University One:- Introduction Definition Insurance is the equitable transfer of the risk of a loss, from one entity to another in exchange for payment. It is a form of risk management primarily used to hedge against the risk of a contingent, uncertain loss. An insurer, or insurance carrier, is a company selling the insurance; the insured, or policyholder, is the person or entity buying the insurance policy. The amount of money to be charged for a certain amount of insurance coverage is called the premium. Risk management, the practice of appraising and controlling risk, has evolved as a discrete field of study and practice. The transaction involves the insured assuming a guaranteed and known relatively small loss in the form of payment to the insurer in exchange for the insurer's promise to compensate (indemnify) the insured in the case of a financial (personal) loss. The insured receives a contract, called the insurance policy, which details the conditions and circumstances under which the insured will be financially compensated. Types of Insurance Services Insurance can take a number of different forms. Some of these types: Auto insurance Auto insurance protects the policyholder against financial loss in the event of an incident involving a vehicle they own, such as...
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...Reporting Practices and Ethics Paper HCS405 July 29, 2012 Professor C. Brew Reporting Practices and Ethics Paper Financial accounting and financial management are the basis for health care accounting. The GAAP is a cornerstone of all accounting practices. Financial management aides and guides health care accounting practices in today’s health care settings. These two elements are the building blocks for a solid health care organization. Without the two, there is risk of fraud and unethical practices within health care. In financial accounting there are four elements of financial management. The first element is planning. In the planning element of financial management, the objective is determined and then the steps needed to reach that objective are identified so that the goal of accomplishing the objective can be met. The second element of financial management is controlling. In controlling the goals set in the planning element are monitored to ensure that the goal is on track. In the controlling stage of planning, managers use reports to track the goals, compare information and to gain feedback on the status of the goals. Organizing and directing is the third financial management element. In this element the manager works daily to track the progress of the goals, reviews daily the results of the organizing and is active daily in the progress of the goals. The final element of financial management is decision making. In the decision making element the financial...
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...Background of Research Various crimes take place in different private and public organisations and institutions every day. This research paper will analyse the different white-collar crimes witnessed in the medical industry worldwide. Practitioners involved numerous health practitioners in the dishonest ways of filling irregular and dishonest information about patients for financial gain. The fraud is generated in many ways depending on the level of need and greed at any particular moment. It should therefore be noted that the amount of fraud committed through white-collar crime in health care has risen enormously (Benson, Madensen & Eck, 2009). Billions of dollars are lost through the various unscrupulous health practitioners and their relevant counterparts. The billions of money fall in the hands of a few people and deprive numerous patients the attention and medication required in the process. The public should therefore be alert and report any suspected cases of criminal injustices in the medical industry (Rosoff, Pontell & Tillman, 2012). Problem Statement It is evident that there are various loopholes in the medical industry where financial fraud occurs and fails to be accounted for in the health organisations. The state is aware of the various modes of White Collar crimes taking place in the medical industry. Similarly, the state with the assistance of the medical officials should implement new regulations to limit the occurrence of white-collar crime (Friedrichs...
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...in a Hospital Setting Darlene V Nickerson Columbia Southern University Abstract Business ethics in a hospital setting includes a review of many areas. Ethical considerations include the areas of patient care, nursing ethics, physician ethics, patient privacy, and medical billing practices. This paper will touch on ethical concerns for each of these topics. Keywords: hospitals, ethics, patient care, nursing, physicians Business Ethics in a Hospital Setting When beginning a discussion of business ethics in a hospital setting it is important to take a broad approach. Because a hospital is a business and also a treatment facility, the ethical concerns must be considered not only for areas such as billing and privacy but also for ethics related to the appropriate care of patients, nursing ethics, and physician ethics. The ethics of the treatment methods employed based on the patient’s condition must also be considered. Ethics and Patient Care I believe that when discussing the ethical implications of patient care it is helpful to review a real-world scenario. One highly publicized case involved Terri Schiavo and her husband’s fight to stop her tube feedings as there was no hope for her recovery (VandeKieft, 2005). One reason for the high visibility of this case in the media occurred because the patient's husband and the patient's family disagreed on the diagnosis (VandeKieft, 2005). Terri suffered a cardiac arrest due to severe hypokalemia (low potassium levels) (VandeKieft...
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...As our gerontologic population is aging, there are many concerns to address. One concern is that older adults are more vulnerable. In this discussion, I will provide two credible articles to reveal the susceptibility that older adults are at risk for. I will also identify key concepts and risks. Furthermore, I will explain how to eliminate or minimize some of these risks. In the older adult population, vulnerability is seeping out from many angles. One major of concern is the area of financial exploitation. Moreover, thefts and scams are rising at a rapid rate. Financial abuse consists of six main domains to include thefts and scams, coercion tied to financial affairs, mismanagement of property or belongings, abuse of trust, a sense...
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...The presence of fraud in the insurance industry is not an unknown one. Health insurance seems to have large number of these fraud cases. A larger point of concern is that as per statistics, 90% of the insurance frauds come from health policies itself. Since the key motive for every fraud is financial profit, there are no exceptions to the people who are involved in it. The involvement of these people in these cases could range from the customer, to the agent, member of hospital in question, or even the employee of the insurance company itself. COMMON OCCURRING FRAUD IN THE INDUSTRY Health frauds can be broadly divided into hard frauds and soft frauds. Each of these categories consists of situations ranging from misinterpretation of facts, to fabrication of documents, and even situations including inflation of claims. Here are some of the malpractices that the industry comes across: * Misrepresentation of facts: This is one of the largest frauds; a case qualifies as misrepresentation when the applicant is completely aware of inaccuracy of the statement provided. The most commonly falsely stated details are regarding the details of medical condition, incorrect personal details such as name, age, identity or even information such as medical history, past claim information and so on. * Fabrication of documents: It is commonly noticed that it often acts as frequent form of fraud related activities that the industry is facing now a days. These documents range from those regarding...
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...Health care Fraud Health care fraud is a crime that has a significant effect on the private and public health care payment system. According to the Federal Bureau of Investigation, all health care programs are subject to fraud with Medicare and Medicaid being the most visible. It is estimated that fraudulent billings to both private and public health care programs are between 3 and 10 percent of total health care programs expenditures. The most recent Centers for Medicare and Medicaid (CMS) statistical estimates project that total health care expenditures are estimated to total $2.4 trillion, representing 14 percent of the gross domestic product. By the year 2016, CMS also estimates that by the year 2016, the total health care spending is to exceed $4.14 trillion, representing 19.6 percent of the GDP. As one can see, the tens of billions of dollars lost due to health care fraud is a serious financial issue that affects the healthcare system as a whole and affects patients, taxpayers, and government through higher health care costs, insurance premiums and taxes. Health care fraud is defined in Title 18, United States Code (U.S.C) s. 1347 as “whoever knowing and willfully executes or attempts to execute a scheme or artifice to defraud any health care benefit program or to obtain, by means of false or fraudulent pretenses, representations or promises, any money or property owned by or under the custody or control of, any health care benefit program.” In other words, it is intentional...
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...Canyon University: HLT- 364 10/11/13 As one studies medical research, they discovers that there are many problems surrounding it. However, one of them can make a tremendous impact, which are, budget cuts. When researching this problem, several questions came arise. How is budget cuts affecting health care administration? Why are there budget cuts? How are budget cuts effecting society? Lastly how was the budget used in the past and if the budget cuts were affected by the actions of those that run research facilities? There are several reasons to why budget is being cut and it is not just one problem that helps explain this. As one goes further into HealthCare research they come to the fact that there are problems that affect this one particular area overall. The first question that arises when inquiring about budget cuts in the health care administration is: Where is the funding they receive going? When there are so many budget cuts and there isn’t enough funding how is this affecting them? As one comes to inquire about budget cuts one has to understand that this affects the health care administration in many ways. As budget cuts arise, problems arise as well. When there is not sufficient money to go around then there are problems as to how much funding does each department receive. As the funding is divided there are shortages that arise. For example, there are shortages in the equipment supply that is needed. A research study indicated that after inquiring of how many hospitals...
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...unsustainable growth in health care costs, there is general agreement on the need to eliminate unnecessary spending in health care--and among the leading candidates are fraud and abuse. Despite ongoing, concerted efforts, making meaningful inroads has not been easy."Fraud" refers to illegal activities in which someone gets something of value without having to pay for it or earn it, such as kickbacks or billing for services that were not provided. "Abuse" occurs when a provider or supplier bends rules or doesn't follow good medical practices, resulting in unnecessary costs or improper payments. Examples include the over-use of services or the providing of unnecessary tests. (Another area, "waste," refers to health care that is not effective, and will be the subject of a separate Health Policy Brief.)Endowed with new powers under the Affordable Care Act and the Small Business Jobs Act of 2010, the Centers for Medicare and Medicaid Services (CMS) has been adopting new tools to curb fraud and abuse in the Medicare and Medicaid programs. The new approach amounts to a paradigm shift from the earlier model, in which CMS paid providers first, then sought to chase down fraud and abuse after the fact--a process known as "pay and chase."This policy brief focuses on eliminating fraud and abuse in Medicare and Medicaid and explores the challenges involved in putting the new tools into place. | What's the background? | The true annual cost of fraud and abuse in health care is not known. In fiscal...
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...medical record number with common identification data elements, for example: patient’s complete name, date of birth, gender, mother’s maiden name and social security number. Because most health care facilities house patient records according to a medical record number, the MP becomes the key to locating paper based records in the health information department file system. Thus, the MPI is retained permanently because it serves as the key to finding the patients record, it can be automated or manual. According to the American Health Information Management Association (AHIMA), some recommended core data elements for indexing and searching records include: * Internal patient Identification * Patient Name * DOB * DOB qualifier * Gender * Race * Ethnicity * Address * Alias/pervious name * SS# * Facility identification * Universal patient identifier (if available) * Account number * Admission date * Discharge date * Service type * Patient disposition 2. What are registers and indexes? Registers and registries contain information about a disease or event and are maintained by individual health care facilities, federal and state government agencies and private organizations. Case report form are submitted by health care facilities and providers to report data to sponsoring agencies, facilities, and organizations. ***Remember, a register is a collection of information, such as a hospital’s admission/discharge...
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