Healthcare Fraud Case Study

“Medical malpractice occurs when a hospital, doctor or other health care professional, through a negligent act or omission, causes an injury to a patient. The negligence might be the result of errors in diagnosis, treatment, aftercare or health management.” (Admin) One of the most common type of claims that pharmacies face are negligence claims. Negligence is one of the categories that falls under the area of law called Torts. In the Hundley v Rite Aid case, a tort was filed for injuries that were sustained by Gabrielle Hundley after she took medication from an incorrectly filed prescription. The case involved a jury trial verdict involving Gabrielle Hundley, a minor child, against Howard Jones, the pharmacist, and the Rite

Medicaid fraud comes in many forms. A provider who bills Medicaid for services that he or she does not provide is committing fraud. Overstating the level of care provided to patients and altering patient records to conceal the deception is fraud. Recipients also commit fraud by failing to report or misrepresenting income, household members, residence, or private health insurance. Facilities have also been known to commit Medicaid fraud through false billing. The Medicare and Medicaid fraud and abuse statute provides that an individual who knowingly and willfully offers, pays, solicits, or receives any remuneration in exchange for referring an individual for the furnishing of any item or service

Illegal activity is something that we all have to aware of and careful to make sure we are not participating in. In the healthcare setting there are so many areas in which someone could attempt to something illegal. There are attempts, successful and unsuccessful, where patients, nurses, physicians, or anyone who is involved in the healthcare setting. As a medical assistant, any knowledge or signs of illegal activity should be reported. You should be able to provide evidence for the reason of accusation.

In the health care business, there are certain standards and laws that have been put in place to protect our patients and their personal health information. When a health care facility fails to protect their patient’s confidential information, the US Government may get involved and facilities may be forced to pay huge sums of money in fines, and risk damaging their reputation.

Physician and pain clinic owner Paramjit Singh Ajrawat, of Potomac, Maryland has been ordered to

Health care fraud and abuse is a significant contributor to high health care spending, resulting in the wasteful spending of health care dollars. The Federal Bureau of Investigation (FBI) and National Health Care Anti-Fraud Association (NHCAA) estimates that 3 to 10 percent of health care dollars are lost to fraud and abuse (Federal Bureau of Investigation, 2010). Fraud is the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the deception could result in some unauthorized benefit to themselves or some other person (Ryan, 2006). Bloomberg reports health care expenditures are rising faster than the rate of inflation and spending in the US has nearly doubled in the last decade and one-half of health care

When providers or patients submit false or misleading information intentionally to a health plan, this is fraud. Some examples of healthcare fraud and abuse include filing claims for services or medications not actually performed or obtained, billing for services for non-covered items using codes for billable services or items, altering medical records, waiving co-pays and deductibles, up coding and unbundling, using someone’s insurance card, billing Medicare patients at a higher fee than non-Medicare patients, and accepting kickbacks for referring patients, to name just a few. Fraud can be committed by hospitals, medical providers, laboratories, pharmacists, billing services, medical equipment suppliers, and even patients. Patients can protect themselves from healthcare fraud and abuse by knowing their healthcare benefits, reviewing the explanation of benefits, asking the doctor to explain the service that was given, report discrepancies, protect insurance cards and member identification numbers, beware of free services, report copayment and deductibles being waived, and never sign blank insurance forms.

6. A breach of confidentiality can result in what consequences for a health care professional? The penalties for violating HIPAA range from civil penalties of up to $100 per person per incident for minor improper disclosures of health information, and up to $25,000 for multiple violations of the same standard in a calendar year. Federal criminal liability for improper disclosure of information or for obtaining information under false pretenses carries sanctions (fines) of $50,000 and one year in prison. The liability for obtaining protected health information under false pretenses with the intent to sell, transfer, or use the information for personal gain or for a malicious action, such as Medicare fraud, carries penalties of $250,000 and/or up to ten years in prison. Severe penalties are in effect if lax security allows health information to be stolen. There is also a risk of a class action suit as well as public relations damage to the institution’s or physician’s image.

Medical fraud and abuse is a huge contributing factor in the rise of healthcare costs in the United States. Although there are many definitions of fraud and abuse, according to Cigna and HIPPA, Medical fraud is false representation of a substance, device or therapeutic system as being beneficial in treating a medical condition, diagnosing a disease, or maintaining a state of health. Medical Abuse is defined as any action that intentionally harms or injures another person. It also involves actions that are inconsistent with accepted, sound medical, business or fiscal practices. Abuse directly or indirectly results in unnecessary costs to medical programs through improper payments. Insurance fraud occurs when companies

So, what is healthcare fraud and abuse is, you may ask? When talking about healthcare fraud and abuse, we are talking about 2 major statutes in the healthcare industry, Physician Self-Referral (Stark) Law and AKS (Anti-Kickback Statutes). These laws apply to many practices and procedures within organizations and can be manipulated to benefit an organization financially. The Physician Self-Referral Law prohibits entities from presenting a claim to anyone for healthcare services for a service not rendered and it also prohibits a physician for creating a referral for services that are designated but are not rendered. AKS prohibits anyone from offering a kickback, paying a kickback, or receiving a kickback in return for the delivery of health care services. However, the AKS encourages referrals based on monetary rewards to the primary source rather than

Deceitfulness, as indicated by repeated lying, use of alias, or conning others for personal profit or pleasure.

illegal acts which are characterized by deceit, concealment, or violation of trust and which are not dependent upon the application or threat of physical force or violence. Individuals and organizations

Healthcare fraud is costly for everybody, as it harms the reputation of the institution or physician committing it, and financially damages the patient being affected.By definition fraud may be defined as intentionally employing surprise, trickery, cunning, deception and unfair ways by which one party cheats another party out of financial resources. In order to educate a healthcare manager regarding fraud , many aspects of fraud must be assessed. This includes the types of fraud, the consequences that come with fraud,the individual(s) committing them, techniques to prevent fraud, and why the healthcare industry is vulnerable to fraud.

The department of Health and Human Services protects and guides the health and well being of individuals here in America (Thacker, 2014). They fulfill these duties providing Americans with adequate and efficient health and human services and monitoring services designed to increase the efficiency of care in the health system (Thacker, 2014). One of the services being monitored by the department of Health and Human Services is the electronic health record system, which carries private and vital information of patient’s health record enabling all eligible participating health workers access to these records (Thacker, 2014). A breach of the protective health information of patients in a health organization creates chaos as these are against the health insurance portability and accountability (HIPAA) law (Thacker, 2014). Hence, measure will have to be put in place to determine what caused the breach and how to rectify it to ensure the breach never happens again (Thacker, 2014).

A business can not work out without an account system, which includes internal. Internal controls are used by companies to make sure financial information is accurate and valid. Strong internal controls are signs of a financially healthy company and protect the company’s integrity. Strong internal controls can also increase a company’s profitability. There are several types of internal controls that companies used to protect themselves such as: Segregation of duties, asset purchases, supervisor review, internal audits and adequate documents and records. This paper will discuss several topics from a case study about And the Fraud