Preventing Fraud, Waste, and abuse Simulation - Essay Example

 Preventing Fraud, Waste, and Abuse Simulation Introduction Simulation has been described as a technique that replaces or can magnify the actual experiences that bring to mind or replicate considerable aspects of the real world in a total interactive manner. Simulation in health care has diverse applications and can be categorized by eleven dimensions. The aims and reasons for simulation, the element of participation, medical care domain, and know-how level of participants, types of skills, knowledge, attitudes or behaviors. Order to use simulation for the improvement of safety in the health care sector will require full integration of its application in to the habitual structures and exercise of medical care. The out come of simulation are difficult to determine especially in terms of benefits and the cost since most of the ocassio0ns that call for its applications are very challenging and may involve a long term use. A range of motivating forces and execution machinery can be expected to push simulation forward, together with professional societies, legal responsibility insurers, medical care payers, and in due course the general public. The prospects of simulation in healthcare fully rely on the dedication and resourcefulness of the healthcare simulation community to see that enhanced patient wellbeing by means of this instrument becomes a reality. General Concern With the increased federal and state government expenditure on health care each year, the concerns of fraud and abuse also increase. A lot of money has been lost to fraud and abuse allegations with CMS estimating about 15 to 25 US dollars per year in Medicaid fraud and close to 1.1 US dollars were recovered in 2005 in false heath care claims. It is with this in mind that all pharmacies have been called upon to safeguard any possible abuse, fraud and waste. It is the obligation of any company to protect itself against fraud, abuse and waste and try to eliminate it completely. Several companies have put in place some policies and procedures that are used to fight fraud, abuse and waste. It’s the obligation of every employee of an organization to put a stop to fraud, abuse and waste, failure to do so may result in the following; 1. the company may have to pay fines 2. the company may be scrapped of the Plan’s network 3. the company may be excluded from the federal Medical care program For individual involvement in either of the scandals, the repercussions include disciplinary actions that may even call for job termination. It is therefore necessary that everybody in the company is conversant with the knowledge of fraud which include how to identify fraud and abuse, prevention, and reporting of abuse and fraud. There are programs that require that all the employees, temporary agencies with employees, contractors and other associates that use these fraud policies and laws, are well compliant so as to cut down the possibility of the consequences and sanctions that are imposed for the contravention. Definition Fraud is described as the deliberate deception or false impression with the aim of getting an unauthorized (illegal) benefit. Waste is defined as the Over exploitation of the services, resources and/or other practices that give an outcome of superfluous costs. Abuse on the other hand is the tendencies of gross actions of negligence or reckless disrespect for the truth in a way that could lead to an unauthorized benefit. These terms are viewed collectively though they carry separate definitions, this could be because any fraud and abuse could actually result in waste. For example; a pharmacist may purposely charge both the patient and Medicare for the total cost of the medication and keep the excess money or after receiving a prescription with a note requiring brand medically necessary, the pharmacist fills in correctly and bills for brand, on the other hand, he replaces with less costly generic alternatives. Government Insights Government agencies have devoted increased financial support and workforce to fighting fraud abuse and waste. The following measures are the main players in the fight against fraud waste and abuse; 1. Establishment of more rules and regulations that prevent fraud waste and abuse 2. They carry out frequent audits and employ more auditors 3. There are more watchdog and law enforcement workforce 4. Increased financial support for new and current ant-fraud programs 5. there are more investigations and legal trials for the violators of the law Categories of Fraud, Waste and Abuse The first category is the false claim; a false claim practically means that one make the government to make payments for an item or service that in reality was not provide or should not have been. It’s as usually referred to as the type one Medicaid and Medicare fraud, waste and abuse. This is regulated by the false claim act which is the principal federal law that was set to prevent false claims that may include; presentation of false claim to the federal government for presentation; causing another party (for example a plan sponsor or pharmacy benefit Manger) to submit a false claim on your behalf to the federal government for compensation; making or using a fake evidence or statement to forward a compensation claim to the federal government; conspiring to get compensation for a false claim; and making or by means of a fake record avoiding or decreasing a responsibility to pay or compensate the federal government. Examples of false claims are request for payment if; forging, alteration or purchasing prescription that were exchanged for other things which are not drugs; charging full prescription when actually it was partly filled with no arrangements for topping up the remainder (shorting); double billing for the same prescriptions; claims made to different payers for the same medication; claims for expensive brand medication when in real sense generics were given and claiming for drugs supposedly dispensed when they were not actually dispensed. Repercussions for player in false claims include heavy financial fines, criminal trial and exclusion from coverage by Medicaid and Medicare programs. On the other hand, the false act protects those who report cases of false claims and no negative consequences are imposed like demotion, suspension, harassment, being fired and no retaliation against them should be made. Kickbacks are another category of Fraud, waste and abuse. This is knowingly and purposively engaging in activities that encourage fraud and abuse. Anti-Kickback statute covers the crimes committed by intentionally and willfully offering, soliciting, receiving and/or paying any fee to promote or reward transfer of patients who accept items or services paid for by a governmental health program. Apart from the false claims and Kickbacks, other fraud cases include gifts given in order to access some services or plan or steering receiver to a particular plan with the intention of cash payment. Compliance Program Compliance program covers code of ethics, compliance officers and committee; trainings; compliance inquiries; employee reporting protection and repercussions for violators. All companies that operate under the policies of anti fraud are required to comply with the legislative and regulatory requirements of the federal and states governments. The key tool that is employed to fight fraud is the code of ethics. A company’s code of ethics is the statement that gives a reflection of the company’s dedication to implement the legal and ethical responsibilities; it gives an explicit explanation of the duties and responsibilities of all employees; and it also gives the repercussions should performance of those duties be breached. The code of ethics usually applies equally to all the employees of the organization and is legally enforceable. The compliance officer leads the company to legal compliance with duties that include; implement the code of ethics, building up, executing and enforcing the overall program; supervising compliance training, reporting compliance cases in the organization; and making follow ups to the reports of suspected fraud and abuse. The compliance officer conducts internal audits of the organizations performance and monitoring the service provision and billing methods to keep track of compliance program. Depending on the size and needs of the organization, a committee can be set to assist the officer. FWA Training The other critical aspect o the program is the training; this is mean to familiarize the employees with the concerns of fraud waste and abuse, the training also provides knowledge on the organizations program, employee’s responsibility under the program, how to identify and report fraud, waste and abuse. Training educates workers on the right they are entitled to if they report incidents of fraud, waste and abuse. Trainings are usually general or specific and are frequently revised to deal with official and realistic developments. The law protects those employees who report fraud against retaliation, demotion, firing, revenge, reproach or disciplinary action. The company should not impose or tolerate retaliation if the report was done in good faith, for possible fraud, waste, and abuse. All the workers of an organization have an obligation to report and supposed fraud, waste and abuse. Failure to comply with these responsibilities can lead to retraining, punitive measures or even being fired from employment. The compliance officer and the compliance committee works together with other departments such as the legal and human resource management to come up with the correct means of action for the violators of the duties. The non retaliation program cannot however be used to protect the employee poor performance, this is to say that any worker who reports cases of fraud will still face disciplinary measures for violation of the organization regulations, poor job performance and poor attendance. Conclusion Centre for Medicaid and Medicare Services (CMS) give the guidelines to be used for drug benefit in Medicare part D. the guidelines help to implement the fraud, abuse and waste program. Non compliant to the program is handled by investigation and if anyone is found guilty of the federal offence, then the possible consequences are; heavy fines, imprisonment, exclusion from Medicare and Medicare programs, and prosecution. References Prescription Drug Benefit Manual – Fraud, Waste, and Abuse retrieved from http://www.cmshhs.gov/prescriptiondrugcovcontra/downloads/PDBManual National Association of Chain Drug Stores: CMS Medicare Part D Fraud, Waste and Abuse Guidance. Impact on Pharmacies retrieved from http://www.pswi.org/government/FWAGuidanceSummary.pdf. Read More