Healthcare: Health Insurance and Fraud E. Ethical

Fraud, Waste and Abuse in the Medicare System: A Proactive Approach Course Project Outline Team A: The Prairie State Bulls Julie GIldemeister Elena Hallars Teresa O’Brien Latia Phelps Laura Wimberley HSM 546 Health Insurance and Managed Care Vernice Johnson-Warren Keller Graduate School of Business Management March 17, 2013 Synopsis We propose to discuss the problem of fraud, waste and abuse in Medicare and Medicaid from the viewpoint of a board of directors of a community healthcare system.We agree that a proactive course of action, while initially more expensive, will result in a far better outcome for the system, its providers, and its patients. It will lead to better relations not only with the government but also with our commercial MCO plans. This issue will be addressed on several fronts: legislative loopholes, weaknesses in electronic technology, ethical lapses on the part of providers, and enforcement failures. I. Executive Summary A. Environment B. Rules and regulati ons of Medicare and Medicaid C.Healthcare Reform Legislation D. Problems with Fraud E. Ethical Considerations of Fraud II. Problem Statement A. Fraud, waste and abuse in the Medicare and Medicaid system B. Legislative loopholes C. Weaknesses in electronic medical records D. Ethical lapses in providers E. Common errors in billing and coding F. Enforcement failures III. Literature Review A. Course text B. Fraud, waste and abuse of Medicare/Medicaid funds C. IT and EMR issues D. Ethical training of providers E. Enforcement failures IV. Problem Analysis A.Identification of opportunities for fraud in a healthcare system B. Enforcement of Medicare/Medicaid claims reporting regulations C. Counteracting or preventing a climate of fraud waste and abuse V. Solutions and Implementation A. Streamlining enforcement efforts B. Tightening IT loopholes C. Creating provider incentives for responsible behavior in coding and billing D. Pattern review and claims review to catch trends indicative of fra ud, waste or abuse VI. Justification A. Cost of fraud, waste and abuse, especially in Medicare claims reclamation processesB. Cost of failure to comply with rules and regulations C. Improvement in facility/provider/payer relations D. Improvement in cash flow and claims payment E. Improvement in patient and community relations VII. Conclusion VIII. References Aldhizer III, G. R. (2009). Medicare and Medicaid Fraud and Errors: A Ticking Time Bomb That Must be Defused. Journal Of Government Financial Management, 58(4), 12-20. Boerner, C. M. (2010). 60 Minutes Story on Medicare Fraud. Journal Of Health Care Compliance, 12(1), 29-65. Dietz, D. K. , & Snyder, H. 2007). Internal control differences between community health centers that did or did not experience fraud. Research In Healthcare Financial Management, 11(1), 91-102. Evans, R. D. , & Porche, D. A. (2005). The nature and frequency of medicare/medicaid fraud and neutralization techniques among speech, occupational, and physical the rapists. Deviant Behavior, 26(3), 253-270. doi:10. 1080/01639620590915167. Hambleton, M. (2011). Los Angeles Health Care Fraud Prevention Summit: Moving from a Sickness to Wellness Model of Compliance.Journal Of Health Care Compliance,13(1), 19-24. Hoppel, A. M. (2012). Career Code Red. (Cover story). Clinician Reviews, 22(10), 1-8. Kongstvedt, P. R. (2007). Essentials of Managed Health Care (5th ed). Sudbury, MA: Jones & Bartlett. Moses, R. E. , & Jones, D. (2011). Physician Assistants in Health Care Fraud: Vicarious Liability. Journal Of Health Care Compliance, 13(2), 51-75. Robin, D. W. , & Gershwin, R. J. (2010). RAC Attack—Medicare Recovery Audit Contractors: What Geriatricians Need to Know. Journal Of The American Geriatrics Society, 58(8), 1576-1578. oi:10. 1111/j. 1532-5415. 2010. 02974. x Sparrow, M. K. (2008). Fraud in the U. S. Health-Care System: Exposing the Vulnerabilities of Automated Payments Systems. Social Research, 75(4), 1151-1180. Steinhoff, J. C. (2008). FORENSIC AUDITING: A Window to Identifying and Combating Fraud, Waste and Abuse. Journal Of Government Financial Management, 57(2), 10-15. Thorpe, N. , Deslich, S. , Sikula, S. , & Coustasse, A. (2012). Combating Medicare Fraud: A Struggling Work In Progress. Franklin Business & Law Journal, 2012(4), 95-107.