Healthcare Fraud : Auditing and Detection Guide - Research Paper Example

? Healthcare Fraud Executive Summary In the United s, healthcare fraud is seen to have grown and still continues to grow at an ever increasing rate of acceleration. Some of the more traditional forms of healthcare fraud are seen to generally include incidences of false claim submissions, employee-plan fraud, controlled substance abuse, the billing of some of the experimental treatments as non-experimental treatments, staged-accident rings, quackery, waivers of deductibles and co-payments bad-faith claim payment activities, kickbacks and overutilization. Some of the more modern evolved forms of healthcare fraud are seen to variously include various program abuse activities that might include the setting aside of some of the discounted drugs and thus making them unavailable to that happen to be in need, pill-mill schemes where prescriptions are falsely billed, organized criminal schemes and counterfeit drug activities (Busch, 2012). The challenges seen to be associated with healthcare fraud are seen to not only be prevalent within the United States but also in a number of other countries as well, The Medicaid and Medicare health programs that are seen to be sponsored by the United States Government are equivalent to a number of government-sponsored programs in a number of other countries and these are also seen to be assailed by widespread fraud (Busch, 2012). Table of Contents Executive Summary 2 The Legal and social Issues that are seen to be Confronting health Service Administrators 4 The Interaction between The Social and Legal Dimensions of Healthcare Fraud 6 Legal Processes in Healthcare Fraud 7 The Research and Communication Skills necessary for Practicing HSO Managers 9 Impact of Healthcare Fraud 10 Recommendations For Improvement and Possible Measures that can be taken to Prevent Future Healthcare Fraud 11 Bibliography 12 The Legal and social Issues that are seen to be Confronting health Service Administrators There are a number of social and legal issues that are seen to currently be confronting most health service administrators in their duties. Some of the inexorable and challenging issues that are seen to be as a result of social trends include: The Demographic Shift Challenge: This challenge is seen to primarily be as a result of the fact that people are currently living longer. This has resulted in causing the numbers of the elderly and very elderly persons to increase at a very fast rate, a factor that is seen to pose a challenge it is this demographic that makes much heavier use of the country’s health care system. The increased longevity of people is seen to be posing a serious challenge to health care administrators at it now costs more for the healthcare system to keep them alive. This demographic is also seen to have a higher likelihood of having a range of complex and chronic health conditions which results in causing the last few months of their lives to become quite expensive (Walshe & Smith, 2011). The demographic challenge is seen to have an added dimension in the form of the rising incidence of chronic disease among the wider population of persons in developed countries. This is largely suspected by the WHO to be as a direct result of increased risk factors such as physical inactivity, tobacco usage and unhealthy diets (Walshe & Smith, 2011). Malpractice: The key legal issue that most health administrators are seen to primarily be concerned with is seen to relate to malpractice. Due to the ever increasing risk of malpractice, healthcare administrators are seen to now seen to ensure that their healthcare offices and the various professionals working in their healthcare institutions carry some form of malpractice insurance. Although it is quite normal for everyone to make a mistake, mistakes make by healthcare professionals can inadvertently negatively impact the safety, health or even the finances of a given patient. In the event of this occurrence, liability is seen to exist that can potentially result in a lawsuit being field against the healthcare institution or healthcare professional. Advancements in Innovations: Innovational advancements in pharmaceuticals, surgery, diagnostics, and other areas have increased the ability of our being able to better control chronic diseases and thus extend life. This is seen to sometimes mean the development of new treatments that although more effective, are usually found to be more expensive as compared to the existing treatments. This poses a challenge as health professionals are sometimes tempted to bill some of these innovational treatments as non-experimental treatments. Changing User and consumer Expectations: Walshe & Smith (2011), argue that people now generally want more form the health service as compared to their parents. They are no longer content to merely be passive healthcare recipients who are prescribed and dispensed by the by the healthcare providers at their convenience. They are now accustomed to ever-widening sovereignty and choice in other areas of life ranging from education and housing to shopping and banking and as such, they are seen to expect to be consulted, involved and informed by their healthcare providers in matters pertaining to any decisions that are seen to affect their health. The current generation is seen to be more articulate, better informed and relatively more likely to know and subsequently demand for new and more often, expensive treatments. Privacy: The law requires that all healthcare professionals and hospitals in the healthcare industry constantly protect the privacy of their patients. Patients are required to provide a great deal of data information so as to be able to access the appropriate or relevant healthcare services. The Health Insurance and Portability Accountability Act, is designed to enforce this measure (Pozgar, 2011). Rising Costs in Healthcare Funding: Healthcare funding is seen to constantly be facing increased pressure as it becomes harder for countries to sufficiently find their healthcare programs. Although most governments are seen to have increased the amount of funding made available to their healthcare programs, this is seen to never be quite enough. While nearly all other areas of economy are experiencing increased an increased productivity that has precipitated a reduction in costs due to increased innovation and competition, healthcare costs are seen to have remained stubbornly high and gradually continue to rise. The Interaction between The Social and Legal Dimensions of Healthcare Fraud As a result of the ever increasing incidences of healthcare fraud in the country, congress passed the health Insurance Portability and Accountability Act that President then signed into law in 1996. The HIPAA helped provide a number of new civil and criminal enforcement tools to be used in fighting against healthcare fraud in the country. Under the HIPAA, the country’s secretary of the Department of Health and Human Services (DHHS) together with the Attorney General are seen to be required to act through the Office of the Inspector General (OIG) to try and established a well coordinated national healthcare fraud and abuse control program. This program is seen to provide an essentially coordinated national framework that can legally be sued by the local, federal and state law enforcement agencies, the pubic and the private sector in effectively combating healthcare fraud across the country. This program is seen to aid in providing the society with a means via which ordinary people can be able to effectively contribute towards combating healthcare fraud in the country. Individual communities and the private sector can now be able to use this program to address any cases of healthcare fraud that might occur within the community, In a concerted bit to try and tackle its set objective, the DHHS is seen to have announced the launch of Operation Restore Trust, which was developed and designed to be an anti-fraud enforcement initiative that is primarily targeted at nursing homes, home care agencies as well as health care durable equipment suppliers. Operation Restore Trust is seen to help in shielding the society from being subjected to healthcare fraud via these institutions and especially so under the home care program that has become quite notorious as a result of its relatively high number of healthcare fraud cases. As a result of the relative difficulty in effectively monitoring home care and the lack of proper accountability to the patients by nurses explaining to the patients exactly which services are being provided, home care fraud is seen to be relatively difficult to detect and insurers are routinely being charged for more services than were actually seen to have been provided, nurses and other care providers are billing their patients for more hours of care than they actually provided and the practice of falsification of documents is seen to be quite rife. However, Operation Restore Trust aims to try and negate the probability of patients in the society from falling victim to this healthcare fraud by trying to carefully monitor the home care services providers. Legal Processes in Healthcare Fraud The numerous initiatives by the country’s federal government aimed at the investigation and subsequent prosecution of various healthcare organizations for healthcare fraud criminal wrongdoing is seen to have resulted in the establishment of various corporate compliance programs and management strategies that have been designed with the multipronged objective of preventing, reporting and detecting any incidences of healthcare fraud related criminal conduct. These management strategy programs and their legal processes are seen to generally involve: The development of various appropriate procedures and policies designed to avoid and handle healthcare fraud. After the development of these policies and procedure, a compliance officer is seen to usually be appointed to oversee the program and ensure that it is successfully implemented and all the various concerned parties are complying with its objectives. Information on the program is also seen to be communicated to the organization’s employees. Auditing and Monitoring systems are also seen to be provided to aid in the detection of criminal conduct by both the employees and as well as other agents. A reporting system for reporting any criminal conduct is also created and publicized and employees and other agents are then encouraged to use in freely reporting cases of criminal conduct within the given organization without having any fear of possible retribution. In the event that any health care fraud related criminal conduct happens to be reported, appropriate steps are seen to be taken in effectively responding to this conduct, this is done simultaneously with attempt to try and prevent the occurrence of similar offences in future. The organization’s anti-health care fraud corporate compliance program I also carefully periodically updated and reviewed to ensure that it constantly remains quite relevant. Policies are implemented to ensure that the organization works with both the state and federal law regulatory and enforcement agencies and insurance companies to obtain their aid in the detection, prevention and prosecution of any cases of healthcare fraud. In an effort to be able to collect all the data necessary for the successful prosecution of a healthcare fraud, healthcare administrators should ensure that they install software into their systems that will help them in the detection and careful recording of healthcare fraud incidences, these records should then be stored safely and forwarded to the relevant authorities for investigation. The Research and Communication Skills necessary for Practicing HSO Managers It is vital that practicing HSO managers have good communication skills if they are to be able to perform their duties in an effective manner. Practicing HSO managers are tasked with the responsibility of always ensuring that they keep up to date with the latest changes in government policies health insurance and the set patient care standards as this will be seen to have a significant effect on both the organization’s staff members and the healthcare consumers. The managers should also be able to identify how these changes will relate to the organization’s protocols and policies. Managers should be able to communicate these changes and their respective effects to their staff members. In addition to this, Health care managers are also seen to be tasked with responsibilities that require that they have good communication skills. These include the frequent writing of memos and reports, the need to make a number of presentations to both the community and the employees in addition to their having to engage in regular talks with the other mangers and strategize on how they can be able to stay sufficiently on top of any of the issues that might happen to arise. Effective Practicing HSO managers should be able to become quite familiar with the particular kind of treatment that is being provided at the medical facility as well as the newly emergent treatments. In order to be able to do this, it is important for practicing HSO managers to ensure that they have the proper research skills that will aid them in conducting the necessary research to provide them with this information. Proper research skills will also aid in providing them with information on how to best utilize the existing talent and staff to the best advantage of the medical facility as well as on how to successfully incorporate any newly emergent best practices in healthcare. Impact of Healthcare Fraud Since the early 1960’s, healthcare costs in the country as seen to have experienced a significant increase from an estimated 28 billion per year to about 1.9 trillion dollars per year as at 2004. Healthcare fraud is commonly perceived to be among the resultant causes of this sharp increase in healthcare costs (Snapshot 2006). With the current estimates according to figures by the FBI indicating that the United States is losing $8 billion due to this fraud (FBI, 2013). Healthcare fraud is seen to critically be affecting numerous citizens in the country as it serves to deny most people access to these vital healthcare services. The monetary resources lost due to this fraud could be used in upgrading the healthcare facilities and enabling them to provide better quality of care to people. The Access and delivery of healthcare services is also seen to be negatively impacted by healthcare fraud is seen to be negatively impacted as the increased healthcare costs resulting from healthcare fraud reduce the funding available that could have been used in improving both the delivery and access to these healthcare services. Recommendations For Improvement and Possible Measures that can be taken to Prevent Future Healthcare Fraud More information should be provided to people on the various healthcare plans in order to educate them on healthcare fraud. Healthcare administrators should encourage people using their healthcare facilities to carefully review for accuracies the reports issued by the insurance companies once their hospital bills have been paid. They should be encouraged to report to the medical facility or insurance company if they find any discrepancies in the list of services provided; these discrepancies might variously pertain to when the services were provided and who proved these services. Healthcare administrators should also carefully examine their claim activity and try to detect any high patient activity or similar procedures being performed on one patient by several providers. By effecting these measures, healthcare providers will not only be able to cause improvements in healthcare by greatly minimizing the cases and instances of healthcare fraud, but they will also be able to prevent future occurrences of this fraud. Bibliography Busch, S. R. (2012). Healthcare fraud : auditing and detection guide. Hoboken, N.J. : John Wiley & Sons. C. H. C. F. (2006). Snapshot Health Care Costs 101. Retrieved on November 21, 2013 from http://www.uquebec.ca/observgo/fichiers/92684_USA%20national%20health%20spend ing.pdf. FBI. (2013). Rooting out health care fraud is central to the well-being of both our citizens and the overall economy. Retrieved on November 21, 2013 from http://www.fbi.gov/about -us/investigate/white_collar/health-care-fraud. Pozgar, D. G. (2012). Legal aspects of health care administration. Sudbury, Mass. : Jones & Bartlett Learning. Walshe, K. & Smith, J. (2011). Healthcare management. Open University Press, McGraw-Hill. Read More