Healthcare Fraud Resulting in Fewer Referrals to Homecare Services - Research Proposal Example

Healthcare Fraud Resulting in Fewer Referrals to Homecare Services Problem ment According to estimates, the United s of America spends between 39 and 100 billion US dollars each year in healthcare. Yet again, over 4 billion worth of healthcare insurance transactions are conducted within the country each year. The amount spent on healthcare almost rises every singly year as medical and healthcare products continue to increase in cost and new markets are introduced in the market. While a lot of money is pent or invested in the US healthcare sector, it is beyond doubt that some of this amount is lost fraudulently in one way or another. In fact, considering that the data on direct losses that is available regarding healthcare fraud today quite significantly underestimates the real value of the cost. While the healthcare fraud may not be very pronounced in the public domain currently, it may not be ignored as it has a potential of growing to astronomic levels given time and left unattended. Fraud has undermined the value of studies on healthcare practices, organization and financing. In the healthcare sector, fraud has presented itself as a multi-faceted demon involving both individuals and corporate organizations. While some officials engaging in the provision of fraudulent or inaccurate data with an aim of getting corporate approval, some organizations engage in the withholding of data that may damage their reputation, the reputation of their products or researchers. The effects of healthcare fraud have far reaching effects on the overall performance of the sector. Cases of fraud have for example impacted negatively the relationship between physicians and patients, and by extension, their relatives. In a bid to cub the problem of healthcare fraud, a number of measures have been introduced by the US government. The new measures have also impacted the way physicians provide services to patients – both in-patient and out-patient. This being the case, it may be postulated that healthcare fraud has had an impact on referrals to healthcare services. This research seeks to establish the existence of a correlation between healthcare fraud and the referral to homecare services. Objectives of the Research Main Objective 1. To establish if healthcare fraud results in fewer referrals to homecare services Specific Objectives 1. To establish the existence of healthcare fraud in hospitals in US, xxxx state 2. To establish the potential effects of healthcare fraud on referrals to homecare facilities 3. To establish the actual effects of healthcare fraud on referrals to homecare facilities Literature Review Homecare Services Homecare caters for a wide range of social, medical and support services. Homecare services are entitled to people such as; the elderly, disabled people, those with long-term health conditions, terminally ill, chronically ill and to people who are recovering (Piper, Roberto and Wacker, 2002). These people are considered to be the most vulnerable people in the population and constant care is needed for their well-being. Care provided may be continuous or intermittent. Continuous care (private-duty care) is provided by other organizations that do not offer intermittent care. Intermittent care is provided by Medicare and other third-party payers. The difference in these two types of care is the length of care delivery. Private-duty care billing is based on the number of hours or shifts spent in delivering care. The service unit is usually longer than 1 hour. On the other hand, intermittent care billing is based on the patient visit. In intermittent care a patient visit is equivalent to a service unit (Kongstvedt, 2001). Professions required to administer care in both cases are different. Highly skilled professionals with strong problem-solving and technical skills are required in providing intermittent care. Support for continuous care people range from ventilator dependent patients to confined or older persons (Kongstvedt, 2001). History of Homecare Services Care has been in existence for a long time. It involved taking care of an ill person in the neighborhood or in a town where the patient lived. Those involved in taking care of a sick person were the medical practitioners, friends and family of the patient. If the medical practitioner was capable of taking care of the patient to some extent considered good, then family and friends would also do the same. As medical education evolved and the need for health care increased, institutional care became a necessity. This shifted care from homes to institutions. With time, the institutions of care became more sophisticated and provided high quality healthcare services. This was due to the increase in the number of patients (Kongstvedt, 2001). Modern homecare started during the cottage industry period. It served people who could not access any medical care. In the mid-1960s homecare services increased due to the passing of Medicare and Medicaid. To access Medicare home health coverage, a person must meet the following qualifying criteria: First, the person must be certified by the physician that he or she needs the services. Second, the person ought to stay under the care of a physician. Third, the person must remain homebound. The person can not move out of the home because of sickness or injury without the assistance of a person or a device and with no much effort. Fourth, the person should have intermittent skilled nursing care or speech therapy or physical therapy. If an elderly adult meets these criteria, he or she may be given occupational therapy, home health aide services and medical social services. Fifth, the home agency providing these services must be certified by Medicare. If an individual meets all the five qualifying criteria, all necessary medical services of the individual will be taken care of by Medicare in full (Piper et al., 2002). States are also allowed to offer homecare services under 3 provisions of the national Medicaid statute. These provisions are; “(a) state plan home health services, (b) state plan optional services, and (c) waiver programs” (Piper et al., 2002). Services offered under the Medicaid state plan whether optional or mandatory, have to meet the following federal requirements; (a) services must be offered equally throughout the state, (b) the recipient must choose freely the services provider, (c) a variety of services must be within the reach of all individuals, and (d) limitations to services must be enough in duration, amount and scope and must attain the aims of the Medicaid program. The services offered by the state must be certified by the state Medicaid agency and the Health Care Financing Administration (HCFA) as cost-effective. Services that states may offer include; home health aide, homemaker, personal care, health care, respite care, habilitation, adult day care and case management (Piper et al., 2002). Types of Homecare Services Skilled services They are offered by a licensed professional health care provider in areas such as physical therapy, speech therapy, nursing, occupational therapy, medical social work and nutrition counseling. Medicare guidelines state that a skilled service can be an initial provision of services that is able to open a case by monitoring a client, creating a plan of care and then supervising home care aides. Nursing services They include observation, assessment, teaching and training, performing direct skilled procedures, management and supervision of a patient’s care. These nursing services are offered by both licensed practical nurses (LPNs) and registered nurses (RN). LPNs can not open a case and therefore access a client and develop a plan of care. For Medicare purposes, a nurse may be the primary care provider in a home. Physical Therapy (PT) Services It concentrates more on improving the movement of large group muscles and gait training. It also addresses joint and muscle pains. For Medicare purposes, a physical therapist may be the main discipline in a home. Speech Therapy (ST) Services These services cater for those clients with difficulty in communication and swallowing. A speech therapist can be the main discipline in a home. Occupational Therapy (OT) Services These services deal with fine motor movements and managing activities of daily living (ADL). Some occupational therapists can also assist clients who have difficulty with swallowing. An occupational therapist is not the main care provider but can continue as a skilled care provider to monitor aides after cases have been established and a plan of care completed by other care providers such as registered nurses, speech therapist and physical therapist. This is according to the Medicare guidelines. Medical Social Workers (MSW) Services These services assist a client in accessing financial services, mental health services and community services. They are of great importance as they assist a client and the caregiver to adjust to emotional, physical, financial and social challenges of an illness. Home Health Aide/Home Care Aide (HHA/HCA) Services Range of care services provided depend on the level of training of the home care aide. There are three levels of home care aide and they are; home care aide, home care aide II and home care aide III. Each home care aide performs different responsibilities in provision of home care aide services (Daniels, 2003). Healthcare Fraud A lot of money is spent on healthcare in the United States and many healthcare insurance transactions are transacted every year. It is estimated that close to 3 billion dollars are spent on healthcare and over 4 billion healthcare insurance transactions are made every year. A small percentage of the transactions made are fraudulent. Money lost to fraud and abuse of healthcare is estimated to be between 39 and 100 billion dollars per year. Fraud is draining a lot of money from Medicare and Medicaid; these two provide necessary healthcare services to millions of low-income, elderly and disabled Americans. Healthcare fraud according to the National Health Care Anti-Fraud Association is a deliberate deception or falsification that an individual or an entity does, with the knowledge that the falsification done would result to unauthorized benefit to the person, entity or to some other parties (Salinger, 2005). Healthcare fraud became a concern in the 1990s when; (a) Costs in providing healthcare increased attracting attention from the policy makers, politicians and criminal justice officials. It is at this time when they realized that a bigger proportion of these costs were due to illegal activities. (b) Legislative bodies lobbied for strict enforcement of illegal or criminal activities in the healthcare field. (c) “Significant changes in the enforcement strategies available to criminal justice officials allowed for the increases in the number of healthcare fraud prosecutions” (Salinger, 2005). Responses to healthcare fraud lead to the enactment of acts such as the Health Insurance Portability and Accountability Act (HIPAA) in the year 1996. The act was able to form a definite criminal offense for healthcare fraud. The offenses were added to the money laundering statutes (Salinger, 2005). The act has strengthened the harmonization between the federal government, states and local government authorities in the enforcement and prosecution of healthcare fraud. Victims and Perpetrators of Healthcare Fraud Majority of healthcare frauds involve relationship between the following four groups; (a) Patients with some type of public or private health insurance coverage. (b) Bodies like government and employers who sponsor healthcare benefit programs. (c) Providers of medical services such as institutions and professionals. (d) Insurance bodies that offer benefits and process claims. Whenever these groups interact, there are higher possibilities of fraud occurring (Fisher and Lab, 2010). Types of Healthcare Fraud These frauds are committed by the patients, caregivers and other parties. They include; upcoding, misrepresenting treatments, phantom billing, performing unnecessary services, unbundling, double billing, billing for services provided by untrained/unlicensed individuals, drug theft, pingponging and illegal kickbacks. Upcoding – This type of fraud involves the provider billing for more broad services than were actually provided to the patient. The provider charges for a service that was not actually given to the patient. For example, a dentist may bill for tooth removal instead of tooth refill. Phantom Billing – In this case a provider bills for services that were not provided to the patient. A provider adds more services that were never given to the patient’s bill. A doctor may bill for multiple service processes that were never provided. Performing Unnecessary Services – The patient is provided with services that he or she does not need by the healthcare provider. The healthcare provider may claim that the process was necessary but actually it was not required. Unbundling – In this case a service that was supposed to be billed as a package is billed separately. For example, services offered to a pregnant woman are supposed to be billed as a package. Double Billing – The healthcare provider bills an agency or a patient for services twice. A healthcare provider may bill a patient and at the same time bill the same amount to the care provider agency. Billing for Services Provided by Untrained/Unlicensed Individuals – A healthcare provider provides services to a patient that he or she is not authorized to perform. For example, a nurse performs services that are supposed to be provided by a doctor. Drug theft – A healthcare provider steals medicine and supplies and the insurance company is billed as if the services were provided to the patient. For example, a pharmacist steals some medicine and bills the insurance company. Pingponging – A patient is referred to other unnecessary healthcare services by a healthcare provider simply to do a favor to the other healthcare provider. A physician may refer a patient to a cardiologist (may be a friend to the physician) and actually the patient had no problems with cardiovascular system. Illegal Kickbacks – Healthcare workers trade their services or funds for referrals. For example, “a nursing home pays for a hospital discharge employee for referrals made to the nursing home” (Salinger, 2005). Effects of Healthcare Fraud It is estimated that United States of America losses a lot of money every year due to healthcare fraud. The cost is estimated to be between 39 and 100 billion dollars per year. The cost of healthcare services continues to increase due to the expansion of the healthcare products market. This means that the cost of healthcare services is becoming expensive with each new day. Direct losses that arise from healthcare frauds underestimate the actual cost of fraud. Fraud has undermined the value of studies on healthcare practices, organization and financing. Some scientists are providing fraudulent data to get approval of the corporate personnel. Corporations and pharmaceutical corporations are also withholding damaging information about their researches and products. The information and products are still been used although they are damaging (Geis and Pontell, 2007). Policy formation is poor and is adversely affected by the fraudulent data being provided. Most healthcare studies rely on Medicare and other data sets and these studies are very vital for the formulation of public policies and development of strategies to cut down the cost of healthcare. Unfortunately most of the data provided has been corrupted by fraud and abuse. “Failure to consider the effects of illegal activities on expanded data sets will likely result in other erroneous policy decisions” (Geis and Pontell, 2007). In other words, wrong and fraudulent data from healthcare research will result in wrong and erroneous formulation of policies and strategies to cut down the cost of healthcare services. Healthcare fraud is increasing the cost of healthcare due to the increasing number of uninsured people. The number of elderly people is directly affecting the cost of healthcare. An increase in the number of elderly people is increasing the cost of healthcare services and insurance. The impact is felt on the patient. Insurance companies are increasing the cost of premiums to cover healthcare services. There is also an upward increase of out-of-pocket expenses and taxes. Many states are cutting down Medicaid coverage due to the continuous increase of healthcare costs, the major catalyst being fraud (Geis and Pontell, 2007). Healthcare fraud especially the Medicare fraud has affected the relationship of the physicians and patients. Due to the rampant increase of Medicare fraud, Medicare fraud enforcements were put into place. The enforcements have negative effects on the physicians and patient care. According to a survey conducted by Association of American Physicians and Surgeons (AAPS), many patients are also feeling the impact of these enforcements. This is because only a few physicians are willing to offer medical services to Medicare-eligible patients. Many of these physicians are restricting their services to Medicare-eligible patients because they fear being prosecuted. Medicare has been branded by many as a corrupt agency, dealing with fraudulent billings and taking millions of dollars of American taxpayers. This may not be the case because there are some honest and qualified physicians who comply with the set guidelines. The Medicare fraud enforcement has made the patients’ access to care almost impossible. Here are some of the findings of the survey conducted by AAPS: Three quarters (around 82 percent) of the physicians fear being prosecuted or investigated. 71 percent of the physicians have made changes in their practices to evade the danger of being prosecuted. Among these changes include restricting care services to certain patients. Around 34 percent of the respondents limit services like surgery to Medicare patients. 20 percent of the physicians surveyed reject new Medicare patients due to the harassment and/or intimidation from Medicare. Around 16 percent cite fees for the services offered. Around 23 percent of the respondents totally reject new Medicare patients. Although they do not accept them at all, 9 percent accept them solely under special circumstances. More than 34 percent of the physicians say that it has become very difficult to find referrals for Medicare patients because many physicians are not willing to accept them. The most disturbing thing is that the physicians who restrict services to Medicare patients do so because of the harassment and intimidation from Medicare. This has made it difficult for patients to get care services from qualified and honest physicians Association of (American Physicians and Surgeons [AAPS], n.d.). Access to healthcare services will remain difficult if the concerns mentioned above are not taken care of. The quality of healthcare services is also affected by these healthcare frauds. The quality of healthcare services is affected in the following ways; (a) Many patients who do not have access to the services due to increased costs result to cheaper service that are not of good quality. (b) Poor products and wrong information provided by some pharmaceuticals and corporations greatly affects the quality of the healthcare services. (c) Policy formulation and implementation if done using the wrong information provided by healthcare agencies, compromises the integrity of the research and the quality of healthcare services. (d) Many physicians according to the survey done by AAPS, fear to provide medical services to certain patients such as Medicare patients due to harassment and intimidation by the agency. Many patients fail to access care services and this is detrimental to their health. (e) Healthcare fraud like “Billing for Services Provided by Untrained/Unlicensed Individuals” compromises the quality of healthcare service provided to the patient. Other than losing money, the patient is at a risk of being poorly treated. Research Methods Research Design and Personnel For this research, both primary and secondary data will be used. Secondary data will be retrieved from various sources including journals, books, medical publications, reputable websites and documents from the health ministry. Primary data will be collected by conducting a survey using mailed questionnaires. This research method will be used considering the nature of data that needs to be captured. Given that detecting healthcare fraud in an institution may not be easy to capture using sent or personal questionnaires, mailing the questionnaires is simpler, more convenient and may prove more effective. This is so considering that institution managers may not be ready to divulge cases of healthcare fraud that exist within their dockets. Furthermore, finding people who have been affected by healthcare fraud in a bid to secure homecare services may not be easy to come by in person. Research Needed Considering the specific objectives of this study, there are a number of questions that will need to be answered by respondents. In particular, the research will determine the existence of healthcare fraud in various cases, respondents’ thoughts on the effects of the vice on homecare as well as the actual effects of the fraud on patients under homecare conditions. Personnel In order to accomplish this research, one research assistant shall be hired and paid for their contributions. The assistant shall engage in postage of the questionnaires and doing the data analysis. In the event that another assistant is deemed necessary, necessary measures shall be taken to hire one other assistant. Research Assurances The survey shall be conducted by the respondents out of free will. This means that no respondent will be forced to take the survey in any case and for any reason. Furthermore, each and every respondent will reserve the right to withdraw from the survey at any point without having to provide any reason or clarification for doing so. The respondents will not be entitled to any compensation or pay for taking the survey. Sample/ Population A sample of 150 respondents will be used for this survey. The sample will consist of people living in the xxxx state, US. The research will be limited to xxx state and shall therefore preclude other states considering that the research would need more time and resources to fully perform a country-wide survey. The respondents will be of legal age to participate in the survey and will be those placed under homecare or those who have been in homecare in the past. The respondents will comprise both males and females and will be chosen randomly. Instrumentation/Data Collection The questionnaire will comprise about 20 questions. The instrument will be divided into sections with the first part representing demographic information and specific location. The other sections of the questionnaire will consist of both open and closed ended questions with the latter being more in number for their easier analyzability. The questionnaires will be designed to be simple enough to understand and in such a manner as to capture the objectives of this survey. Planned Method of Analysis The data gotten from the field will be analyzed statistically using SPSS software. Apart from determining the mean, mode and medians for different variables, correlation and regression analyses will be conducted. The latter two analyses will ensure that the relationship between healthcare fraud and homecare attendance is well established. The hypothesis that there is an effect of healthcare fraud on homecare referral will also be tested using Chi square test. Time Schedule The value and importance of time as a resource cannot be overemphasized more so considering that it is non-renewable. This research is expected to take a maximum of 10 week considering that unpredictable nature of online surveys. This time schedule considers the various activities that will be conducted during the research, giving little allowance for unforeseeable circumstances. It is however hoped that nothing will crop up as to disorganize the schedule of activities. In case the schedule presented below is disorganized for some reason, a new schedule will be adopted to compensate for any lost time. Table 1: Time Schedule Activity Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 8 Week 9 Week 10 Preliminary Preparations Reading and Reviewing Literature Review the secondary data Pilot Test and questionnaire revision Administering questionnaire Data Analysis Report Writing Submission and Presentation of Report Research Budget Every project demands the allocation of resources of various kinds. Similarly, this research will demand the allocation of funds and time for its successful completion. This section will outline the budget that will be applied for its completion. Table 2: Budget (in US Dollars) Items Total Cost (in US Dollars) Stationary 60 Photocopying & Printing Costs 50 Report Binding 20 Mailing Costs 100 Travel expenses 100 Online questionnaire development and hosting 400 Data Analysis Costs 200 Workers Fees 300 10% Contingency 105 Total Expenses 1155 References Association of American Physicians and Surgeons [AAPS]. (n.d.). AAPS report on Medicare fraud. Tucson, AZ: Author. Daniels, R. (2003). Nursing fundamentals: Caring & clinical decision making. Belmont, CA: Cengage Learning. Fisher, B. S. & Lab, S. P. (2010). Encyclopedia of victimology and crime prevention, volume 1. Thousand oaks, CA: SAGE. Geis, G. & Pontell, H. N. (2007). International handbook of white-collar and corporate crime. Spring Street, NY: Springer Science + Business Media. Kongstvedt, P. R. (2001). The managed health care handbook. Sudbury, MA: Jones & Bartlett Learning. Piper, L. E., Roberto, K. A., & Wacker, R. R. (2002). Community resources for older adults: Programs and services in an era of change. Thousand Oaks, CA: Pine Forge Press. Salinger, L. M. (2005). Encyclopedia of white-collar & corporate crime: A – 1, Volume 1. Thousand oaks, CA: SAGE. Xxxx Topic:  Healthcare Fraud Resulting in Fewer Referrals to Homecare Services Instructions: The research proposal should be double-spaced and All of the following are required: Problem statement Related Research/Lit Review Objectives Research Methods Population/Sample Research Design Instrumentation/Data Collection Planned Method of Analysis Time Schedule Research Needed Personnel Budget Needed Assurances Read More