Fraud and Abuse Case Healthcare fraud and abuse continues to threaten the country, costing the facility billions of dollars per year. Brodeur, (2007) stated that fraud is something difficult to understand because it is a contagious issue. Healthcare fraud and abuse according to Brosman & Roper (2007) is the most profitable thing one can take part in if he/she is a crook, it avoid all channels and legal procedures, in nutshell, have no hurdles.

Commonly types of healthcare fraud and abuse cases are revealed where one bill for services not offered, up coding which refers to hiking bills with intention to get higher reimbursement increment. Unbundling which entails submission of separate bills for single component of an activity for example billing independently for categories of laboratory tests done together with the aim of getting high reimbursement. These fraud activities are against compliance laws and regulations and it is unethical and immoral behavior.

Recently I received a call on my hotline regarding a potential fraud and abuse that was taking place in an hospital facility, the compliant poured his grievances saying that one of their doctors was billing for services that had not been provided, he went on to stress that this behavior if not urgently addressed will lead to lose of reimbursement of Medicare and Medicaid.

Thorough investigation revealed that Medicare and Medicaid fraud and abuse cases are rampant in hospital facilities. Examination of the facility data done to enable identification of culprits, by doing this it alerted the facility to be informed of certain abuses and become the eye-opener to bring civil and administrative action against such facility and individuals concerned. Statistical data over several years was also investigated and analyzed.

From the interviews conducted whereby several bodies were involved for instance staff residents, the customers and management it revealed that there was higher practices of fraud and abuse. Some of the questions asked include forms of fraud and abuse cases practiced, different responses and reactions was experienced from the whistle blower, management and staff residents. Some of the mentioned kinds included; up coding whereby providers would bill for services they never provided this is common among physicians, unbundling whereby lab technicians had a habit of giving out separate bills for independent components of tests, stark violation this was majorly performed by doctors who referred patients to a facility with some expectation or something in return (Brosman & Roper, 2007). Some patients were interviewed concerning quality of services offered some were dissatisfied while others were satisfied this revealed that there was a problem that needed to be addressed.

With the help of a whistle blower the name of the person suspected, Dr. Greedy through thorough investigation revealed that he has really expanded his belly and robbed the facility quite a lot of money through his engagement in fraud and abuse by billing for services that had not been provided. Dr. Greedy an ophthalmologist who billed for laser surgery he did not offer, as aspect of proof, laser equipment or access of such equipment at the place of services as stated in the form was nowhere to be found the date of service was blank indicating that no activity took place.

As proved that fraud and abuse cases have been going on action should be taken to safeguard losing reimbursement for Medicare and Medicaid programs. Dr. Greedy found to have a case to answer a disciplinary action will be taken for failure to comply with applicable laws and regulations he was eventually suspended.

Ethics and Morals

The service providers have responsibility to maintain accurate and honest records relating to all services, to give out the correct billing of all payers and to follow all laws and regulations relating Medicare and Medicaid coding and billing practices. All employees should conduct their activities in ethical, legal and competent manner

According to Brodeur (2006) ethics are planned process of reflection in which issues of what one morally ought to do are scrutinized, evaluated and decided through moral reasoning that encompasses but not limited to principles and theories. Ethical behavior is important in healthcare environment though human beings with their money minded attitude have tried to act contrary of what they are expected.

Canavan (2006) suggested that some aspects like power, trust, inclusion, and role flexibility should be incorporated for employees to practice in ethical and moral manner to expand on this inclusion is realized when the employees have the right to receive accurate information, they should be free to express themselves that's power and free to argue and disagree about some issues.

In every health facility, codes of ethics are set forth to guide participants'...

The code of ethics in a hospital facility serves the following purposes:
Establishes a set of framework for professional behavior and responsibilities when professional obligations or ethical uncertainties arise.

Enhancing accountability of the facility so that the public can rely upon

Promotes high standards of hospital facility practice

Summarizes large ethical principles that reflect the professions core values

Some code of ethics principles and guidelines include:

Confidentiality and privacy. Health information management professionals are endowed with responsibility to safeguard all confidential information that the patient reveals to him/her it extends to the tests, financial and genetics.

Reporting unethical practices. The practitioner should take an immediate action of reporting any unethical activities for example fraud and abuse undertaken by a colleague and if there is incompetence.

Positive representation of the profession to the public. The practitioner should ensure that he/she provides full representation to his clients since they rely on their assistance.

Respect. Promoting the value of self-determination for each individual, the service provider should not look down upon or despise anyone.

Truthfulness. Presenting valid credentials and rewarding where it deserves, that is biasness should be the thing of the past.

Acting as an example. Service providers are seen as mentors to the students, peers, and new health management professionals so as to be able to develop and strengthen skills.

Ethical behavior in most facilities has been corrupted by individuals who are profit minded, this gives impression that something bad will happen for the ethical provision of healthcare services .survey undertaken revealed some of the ethical and moral components that healthcare providers and healthcare facilities face with fraud and abuse.

Failure of governing body to make sure that contractor of services furnishes services that enable hospital to comply with all laid down requirement of participation and standard of contracted services

Failure of the hospital facility to take part in hospitals Continuous Quality Performance Improvement Program relative to general services, a lot of negligence and ignorance experienced.

Mishandling records whereby current and accurate records were not taken concerning the number of patients attended to and duration of services.

The hospital did not reveal clearly the list of all contracted services, including the type and nature of the service provided.

Failure of the hospital to analyze and identify quality indicators including adverse patient period and other aspects of operation that aid in cure, hospital services and operations

Lack of accountability from medical staff and administrative officials in ensuring quality improvement of the services provided is implemented and maintained.

Lack of hospital procedure technique that would enhance quick reporting of fraud and abuse cases

There is need to create an ethical organizational culture, according to Brosman & Roper (2007), for an organization to succeed in implementation of ethics a four-site procedure should be used as a guide where the first step involves formalization to prove and grasp the organizations values and linking them with mission and vision statement, second facilitating communication and learning about ethics, third creating a structure that fosters and support the ethical culture and finally, conducting frequent follow up and evaluation on ethical performances.

In summary ethically justifiable behavior comprises of morally correct decisions and actions in which the interest of the society is factored in first over the interests of individual. This ultimately is a shout to a higher not a lower standard for healthcare organization.

Correction Action Plan

A well-defined strategy has been developed to help practitioners cope with the ongoing demands of Medicare and Medicaid compliance this include; education which has been made possible through organizing seminars on variety of topics such as, Medicare documentation requirement, coding and billing, and medical record audits.

The facility also offers personalized assistance whereby reimbursement assistance is provided in response to questions over the phone. Availability of resource kits to provide informational material on practitioner practices and appointment of numerous consultants who can assist when fraud and abuse issues arise.

With increase in fraud and investigations a corrective plan to deal with these cases should be implemented, developing some form of compliance program is quite advisable, application of laws and regulations.

Auditing and monitoring

This is done by reviewing policies and standards and identification of risk areas. Policies and standards should be updated periodically to ensure they are not obsolete, review of current work plan and semiannual reports done to be able to identify the risks that have come up. In the case of fraud and abuse cases risk areas identified include; improper coding and billing, avoidance of improper inducements, encoding, unbundling.

When carrying out a baseline audit, risks areas are factored in especially when performing an internal review.…