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Healthcare Fraud

Need help with a healthcare class.

See assignment below.

The funding and reimbursement aspects of health care delivery are complicated, transaction-oriented, and subject to applicable laws and regulations. The sheer volume of transactions and myriad nuances of patient care make the process of documenting services delivered and payments received even more complex. Unfortunately, motive and opportunity to commit fraud often find health care organizations an ideal target for criminal activities given this volume of complex transactions.

You have been retained as a consultant by a large health care organization that wants to take a proactive approach to fraud prevention by increasing employee awareness. They have asked you to provide a report outlining how you would develop a training program for managers that will help them learn to do the following:
Analyze health care fraud and the consequences of health care fraud on the following: Patient
Health care provider
Institutions involved
Others

Assess the concerns of a manager pertaining to the receipt of payment for services rendered.
Evaluate the impact of payments or delays in payment on budgeting and planning.

Solution Preview

Health Care Fraud and Industry Structure in the United States. Academic Journal By: Skeen, James W. Social Policy & Administration. Oct2003, Vol. 37 Issue 5, p516. 14p
Combating Medicare Fraud: A Struggling Work In Progress. Academic Journal By: Thorpe, Natalie; Deslich, Stacie; Sikula, Sr., Andrew; Coustasse, Alberto. Franklin Business & Law Journal , 2012, Vol. 2012 Issue 4, p95-107, 13p
http://www.nhcaa.org/resources/health-care-anti-fraud-resources/the-challenge-of-health-care-fraud.aspx
http://www.mbrbilling.com/news/articles/bid/86298/Medical-Billing-Fraud-and-Abuse-What-is-the-Carrier-s-responsibility

When establishing a training program to make employees aware of the problem of healthcare fraud, the depth and scope of the issue must be highlighted. The United States has spent approximately $2.6 trillion in 2011, with over 10% of this suspected to be fraud payments. Therefore, employees must be cognizant of the reasons that have made fraud one of the leading causes of health care expenses in America. The training program must be able to relay to workers the many different forms of healthcare fraud that exist so that employees will be cognizant of what to avoid in regard to questionable practices that may result in fraud.

Overutilization, up-coding, billing for services that weren't performed and filing false cost reports are some of the ways that physicians and clinics defraud the federal government. Fraud is endemic in the healthcare industry and systematic in some sectors because of the fact that it is extremely difficult to detect. The reasons for fraud are that it is hard to detect, a lack of ...

Solution Summary

Healthcare fraud.

$2.19