HI215 Unit 9: DBDescription
Two Parts Part One: Initial Discussion posts should be in the range of 150 words. Part Two: Responses to your classmates or instructor should be around 62 words each Two Parts, Part One: Initial Discussion posts should be in the range of 150 words. Fraud and Abuse For this Discussion, review the following scenario and answer the questions below. While working at the medical office where you are a reimbursement specialist, you notice that a Medicare patient has many more laboratory tests done than a non-Medicare patient. Consider these questions in your initial post to the Discussion Board. • What is the difference between fraud and abuse? • Could this be a case of fraud or abuse? Why or why not? • Is it appropriate to notify your office manager? • How would you go about investigating this particular case? What would you review? How would you proceed? • What is the impact of having fraud and abuse occur at your facility? Part Two: Responses to your classmates or instructor should be around 62 words each Classmate: Nadia Hanna What is the difference between fraud and abuse? Fraud and abuse are a bit the same, but have differences where you are able to detain, with a situation that happening. Fraud is the act of deceiving, knowingly doing something illegally or animposer. Abuse is maltreatment whether it be physical or verbal and the excessive use. • Could this be a case of fraud or abuse? Why or why not? My personal opinion with this case, can be both, because fraud is the act of deceiving and they did deceive, because doing more test it could have been done to try and gain more money from the insurance company. The abuse, because you have done excessive amounts of test and referrals and that is against federal regulation. Now, if the patient was to be doing test and paying for those test out of pocket, then that will be fine, but in this case it does not look like that. • Is it appropriate to notify your office manager? Yes, the Office manager would need to be notified and if the Office Manager is following up behind, documents that are coming in and need to be revised, they should notice it as well. Office Managers tend to get a bit busy, but if there is something they may not have seen and bring it to their attention. • How would you go about investigating this particular case? What would you review? How would you proceed? I would need to speak to the physician, find out why so many tests were needed and if he sees something that is a major concern and they feel further test were needed to cover all areas to properly diagnosis and treat the patient. • What is the impact of having fraud and abuse occur at your facility? This can cause fines, imprisonment, losing your license and loosen their funding from the state. Classmate: Jasmine Young The difference between fraud and abuse is “fraud is an intentional deception or misrepresentation of services that an individual knows to be false and could result in an unauthorized reimbursement to a practice. Abuse describes incidents or practices inconsistent with accepted and sound medical, business, or fiscal practices.” I would say this is a case of abuse. Medicare recipients are being used to get more reimbursements for laboratory test that may not be medically necessary. In this case it is appropriate to notify the office manager of such findings. A thorough investigation of Medicare recipients/patient’s chart need to be reviewed to determine whether or not the laboratory test were medically necessary and actually provided to the patients. According to The Rheumatologist website, “When fraud has been committed, the government can seek federal criminal conviction, take administrative actions to exclude the responsible parties from the Medicare program, or suspend the provider from the Medicare program altogether. In addition, monetary penalties may be imposed at the discretion of the Department of Health and Human Services (HHS) secretary. Violations could cost a health professional up to $10,000 per claim. Abuse is considered a lesser offense, happening when practices do not follow proper coding and billing guidelines. When abuse is committed, the government usually recovers payments made in error and sometimes suspends the abusive provider from the Medicare program…” www.the-rheumatologist.org/article/fraud-and-abuse-whats-the-difference/