...T ackling Fraud, Waste, and Abuse in the M edicare and Medicaid Programs: R esponse to the May 2 Open Letter to the Healthcare Community Dan Olson, CFE June 2012 Tackling Fraud, Waste, and Abuse in the Medicare and Medicaid Programs White Paper C ontents I. Introduction ............................................................................................................ 1 II. Recommendations................................................................................................... 3 Recommendation 1 – Expand the Medicare Fraud Strike Force Model....................................... 3 Potential Savings .......................................................................................................................... 4 Recommendation 2 – Expand Integrated Data Repository .......................................................... 4 Potential Savings .......................................................................................................................... 5 Recommendation 3 – Expand “Do Not Pay List” .......................................................................... 5 Potential Savings .......................................................................................................................... 6 Recommendation 4 – Publicize Drug Expiration Dates ................................................................ 6 Potential Savings ....................................................................
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...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 year 2011 Medicare spent $565 billion on behalf of its 48.7 million beneficiaries, while federal and state Medicaid agencies served 70 million people at a combined cost of $428 billion. CMS estimated that in fiscal year 2010 these two programs made more than $65 billion in "improper federal payments," defined as payments that should not...
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...required to maintain licensure, certification, and accreditation in order to receive payments from federal government programs such as Medicare. Healthcare facilities must meet the minimum standards in order to operate, such as sufficient staffing, personnel employed to provide services, the quality of equipment, buildings, and supplies, and services provided, including health records. (LaTour, 2013) Medicare has developed Conditions of Participation and Conditions for Coverage, which identifies specific criteria that must be met in order to receive reimbursement from Medicare. Medicare implements these guidelines in order to set a standard for improving quality of care and maintaining the health and safety of its beneficiaries. (CMS, 2013) State agencies conduct annual surveys of licensed facilties to ensure they are operating at or above the minimum standards set forth by the sate and CMS. It is imperative for licensed healthcare agencies to meet the guidelines of the Conditions of Participation in order to receive reimbursement, if they do not meet the minimum standards they could be unable to participate with Medicare, thus losing patients and revenue. Physician Quality Reporting System requires healthcare providers and hospitals to meet clinical quality standards and record them. Physician Quality Reporting System is a program implemented by Medicare that uses incentive payments and incentive adjustments in order to promote reporting of quality information from its eligible...
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...Medicare Fraud: The History, Incidence, Costs and Institutional Remedies John H Everett Wayland Baptist Medicare Fraud: The History, Incidence, Costs and Institutional Remedies What is Medicare fraud? ("F&A," 2011, p. 1) states “Medicare fraud happens when Medicare is billed for services or supplies you never got. Medicare fraud costs Medicare a lot of money each year.” What is Medicare abuse? ("F&A," 2011, p. 1) defines this as “Abuse occurs when doctors or suppliers don’t follow good medical practices, resulting in unnecessary costs to Medicare, improper payment, or services that aren’t medically necessary.” In reviewing the definitions of fraud and abuse by Medicare it may be hard for some people to understand if they do not live in the healthcare world daily. In an effort to help shed some light on this, we will look at the history of Medicare fraud. It has been around since the Civil War, when the False Claims Act (FCA) was created. It was also called the Qui Tam Statue meaning “he who sues for the king as himself.” ("FCA," 2011, p. 1) “The law was targeted at stopping dishonest suppliers to the military Union military at a time when the war effort made it all but impossible for the government to investigate and prosecute the fraud itself. Today it serves a similar purpose because of the enormous size of the federal government and the variety or programs under which it expends taxpayer funds.” In 1986 the FCA has been revised over the...
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...Dealing with Fraud Liquid Professor Beharry Health Care Policy, Law, and Ethics March 18, 2013 Abstract This paper will evaluate how the Healthcare Qui Tam affects health care organizations while providing (4) examples of Qui Tam cases that exist in a variety of health care organizations. Other responsibilities discussed, are devising a procedure for admission into a health care facility that upholds the law about the required number of Medicare and Medicaid referrals; the ability to recommend a corporate integrity program that will mitigate incidents of fraud and assess how the recommendation will impact issues of reproduction and birth. The know how to devise a plan to protect patient information that complies with all necessary laws. Evaluate how the Healthcare Qui Tam affects health care organizations. The Healthcare Qui Tam affects health care organizations in that well over more than 450 hospitals across the country were the subject of Medicare fraud investigations. Whether or not Medicare violations are found, the costs of responding to an investigation can be significant. Westchester Medical Center of New York, being investigated for possible health care fraud and violations of anti-kickback laws, received a subpoena for extensive records in some thirty-seven categories going back to 1997. Millions of dollars may be spent in legal fees and other costs associated with the investigation (e.g., hiring or reassigning staff to assist with compiling...
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...The whistleblower (or “qui tam”) supplies of the False Claims Act let private people to bring suit on behalf of the government against persons or business who have present fake assert to the government. Under the Act, a whistleblower is 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...
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...Introduction: Working as a financial manager comes with a lot of responsibility; and a lot of standards of practice. Just like physicians and nurses, financial managers of health care organization have a set of rules and ethical guidelines they must follow in their practices. In this paper, will cover the four financial management elements crucial to the health care organization. There will also be a summary of generally accepted accounting principles (GAAP) and financial ethical standards. I will also provide examples from articles that explain how corporations comply with these standards and deal with fraud or abuse. The four fundamentals of monetary management are controlling, decision-making, organizing, and planning. Planning helps the financial manager to identify the necessary steps that must be taken in order to accomplish the organization’s objectives. Controlling, helps ensure the successful execution of each step and all plans that are being followed and performed by the designated areas of the organizations. The organizing and directing element refers to the finance manager utilizing the organizations resources and deciding what is best to use that will help each objective be reached. In addition to that, this element also refers to the daily overseeing of operations that the health care organization is running efficiently. The last element which is decision making happens throughout the entire process of planning, controlling, organizing and directing because...
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...(“Discipline,” as used throughout this policy shall include all steps described in the Human Resource policy manual and faculty policies and regulations including, without limitation, termination and tenure revocation). This Plan provides for oversight by a Compliance Program Medical Director and Compliance Officer. Although the intent is to encourage compliance through a centralized audit system, it remains the responsibility of each individual involved with the billing process, from physicians and other providers to clerical staff, to comply with the law. The purpose of this Plan is to ensure that clinical services are adequately documented and that properly coded bills are submitted only for documented services. This Plan is to be read in conjunction with and is an integral part of the University of Rochester Medical Center Compliance Plan, which is set forth in a separate document. In addition, it is anticipated that individual departments of the University will create specialty-specific billing compliance plans, which will be subject to review by the Compliance Program Medical Director and Compliance Officer. The University acknowledges that this plan is only the beginning of its efforts to institute a program and oversee compliance with applicable laws and regulations. The key to success, in which all employees play a part, is ongoing adherence to the highest standards of conduct and the development of a workable system in which employees are educated about compliance...
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... higher quality healthcare to families, seniors, businesses, and taxpayers. The program includes those Americans without insurance and those with inadequate coverage on their existing plans. The plan has been also called “Obama Care” as it was enacted under the leadership of President Obama. 1 Medicaid, which currently covers nearly 50 million low-income Americans is a federal/state partnership of which all 50 states participate. Significant variations exist among states, however, they must meet federal minimum requirements. The Affordable Care Act of 2010, expanded Medicaid to all...
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...Medicare fraud is becoming a huge problem in today’s society. Medicare is a health insurance program for personnel paid by taxes the American population contributes to for personnel 65 years or older. When a health care provider, health suppliers, and private health companies deliberately bill Medicare for supplies or services that were not given is considered Medicare Fraud. To include, when a person uses another person’s Medicare card to receive health care for which the person does not qualify for. An individual, company, or a group can commit a Medicare fraud scheme. Medicare Fraud Scheme A physician, office manager for the physician’s medical practice, and five owners of health care agencies were arrested for charges related to the alleged participation in nearly a $375 million health care scheme. The Medicare Fraud scheme is the biggest in history. The scheme included fraudulent claims for home health care services. The physician, Jacques Roy, owned and operated Medistat Groud Associates P.A. in Dallas. The business included health care providers that primarily provided home health certifications and performed patient home visits. Dr. Roy allegedly certified or directed the certification of more than 11, 000 individual patients from more than 500 Home Health Agencies from January 2006 to November 2011. Medistat certified more Medicare beneficiaries for health services and had more purported patients than any other medical practice in the United States. Basically, Dr...
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...Dealing with Fraud By: Kevin McCarthy To: Dr. Michelle Rose HSA 515 Health Care Policy, Law, and Ethics December 13, 2012 Abstract As the Chief Nursing Officer, I am responsible for one of the state’s largest Obstetric Health Care Centers. I have received word of some fraudulent behaviors in the center. I will evaluate how the Healthcare Qui Tam affects health care organizations. I will provide four (4) examples of Qui Tam cases that exist in a variety of health care organizations. I will devise a procedure for admission into a health care facility that upholds the law about the required number of Medicare and Medicaid referrals. I will recommend a corporate integrity program that will mitigate incidents of fraud and assess how the recommendation will impact issues of reproduction and birth. I will devise a plan to protect patient information that complies with all necessary laws. Evaluate how the Healthcare Qui Tam affects health care organizations Qui tam is shorthand for a Latin phrase that means “he who sues for the king as well as for himself.” In a qui tam case, the whistle – blower (aka relator) files the suit as a kind of “private attorney general” on behalf of the government. The government can choose to take over the prosecution, but if it declines to do so the relator can proceed alone (Showalter). Any person with information about health care fraud can be a qui tam plaintiff. Person is defined as “any natural person, partnership, corporation, association...
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...Reporting Practices and Ethics Paper Reporting Practices and Ethics Paper Introduction In the health care industry organizations have to create guidelines and principles in order to successfully succeed. Implementing the four key elements of financial management and federally enforced principles are not enough. Ethics has also played a big role in the success of an organization. Many companies set up their own professional guidelines so that all employees maintain the same goal and success. However, as individuals every person has their own perception of personal ethics and sometimes can cause a struggle in certain workplace situation. Developing structure in an organization allows each department to operate to its fullest potential. In a health care organization the accounting department is considered the backbone of the organization. In accordance to, (Hicks, 2013) without an accounting department, it would be impossible for any type of organization to operate in a cost effective manner. The key elements of Financial Management There are four key elements that are recognized and implemented by financial management. The four elements are: Planning, Controlling, Organizing and Directing and Decision Making. An organization can become successful and accomplish goals by setting guidelines utilizing the element of planning. The second element used to succeed is controlling which ensures for all areas of an organization to follow previous planned goals and guidelines...
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...Meaningful Use Information Technology in Healthcare Mohammad Ali Torabi Meaningful Use In 2009 president Obama signed the Affordable Care Act, which is also known as ObamaCare, into law. ObamaCare is a national health care plan, which its main goal is to reform the American health care system so that every citizen would be insured by the year 2014. Healthcare providers are overwhelmed by the amount of patients they visit everyday due to the shortage of doctors we are having. One article from New York Times estimated that by the year 2025, America would be in shortage of 100,000 primary care physicians, based on the amount of doctors graduating and an increase demand of healthcare. Having said this, the atmospheric state in the healthcare environment can be described as barred linear unit in which everything within is in an incessant movement, whether it’s the personal, semantic role, and/or the application. In this crucial environment, access to patients’ medical record in a timely manner is essential in providing efficient and quality patient care. In a town meeting held in Northern Virginia Community College in Annandale, Va., President Obama called for fixing the inoperative healthcare system by investing in electronic medical records. President stated, “ I know that people say the costs of fixing our problems are great – and in some cases, they are”. He also stated that, “The costs of inaction, of not doing anything, are even greater. They’re unacceptable.” In an...
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...element of this situation is that recent cases have shown that medical professionals are more willing to risk patient harm in pursuit of successfully executing their schemes. Health Care fraud is in the jurisdiction of the FBI. They are the primary agency responsible for investigating these types of cases, and also for exposing them. They are responsible for the federal and private insurance programs. As the Chief Medical Officer of a large Obstetrics Health Care Center, I am sadden and extremely angry to learn that these types of fraudulent activities are associated with my facility. As I investigate and learn more about the situation, I will also be exploring other topics as listed below. 1. Evaluate how the Healthcare Qui Tam affects health care organizations. 2. Provide four (4) examples of Qui Tam cases that exist in a variety of health care organizations. 3. Devise a procedure for admission into a health care facility that upholds the law about the required number of Medicare and Medicaid referrals. 4. Recommend a corporate integrity program that will mitigate incidents of fraud and assess how the recommendation will...
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...Health Insurance Portability and Accountability Act (HIPAA) HIPAA was put in place to maintain disclosure of medical records which includes maintaining privacy rules on disclosure of patient information and identity. Privacy and security needs to be maintained in other to protect the services of patients, reducing ethics violations, sustaining corporate integrity as well as to increase patient satisfaction. The health care setting in which HIPPA will be used is all healthcare settings, such as hospitals, clinics, pharmacy, insurances and HMO’S. All healthcare professionals must obey all HIPPA rules and regulations to avoid penalties (Mir 2011). Privacy and security needs to be maintained in other to protect the services of patients, reducing ethics violations, sustaining corporate integrity as well as to increase patient satisfaction. Electronic Medical Record An electronic record can be defined as a health or medical information of a particular patient or individual which is generated, and taking care of by authorized healthcare professionals or health care organization. The health care setting that uses electronic medical record is hospital, physician’s office, and medical health professionals. They input the medical records such as diagnosis, test results and past records of treatment and drugs in the computerized system for safe keeping and follow up. Electronic Health Record An electronic record can be defined as centrally health information of a patient...
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