Module Two Discussion: Billing Fraud and Abuse
Billing fraud and abuse has become an exponen al problem within the healthcare system,
causing a nancial burden resul ng in the enactment of laws and regula ons, along with tasks forces and coali ons to combat this problem. Hospitals create processes that meet standards within their billing departments to remain in compliance with local, state, and federal rules and regula ons and provide fair
cause of noncompliance with hospital standards, and the intent of the individual will determine if fraud or abuse was conducted and to what extent. Fraud cons tutes falsifying informa on to obtain payment where not en tled or recommending treatments or procedures to receive kickbacks (Medicare Fraud and Abuse, 2021). It essen ally sounds like stealing to me. Abuse, by contrast, is recommenda on or performance of care that results in unnecessary cost - the intent determines commi al of fraud versus abuse (Medicare Fraud and Abuse, 2021). Accidental fraud or abuse is always a possibility and must be determined to remediate the situa on.
Noncompliance with hospital standards poses risk to the billing specialist's posi on -- this is
depending on the individual's knowledge of his wrongdoings and intent in doing so. A lack of educa on or training could be the cause of noncompliance, but self interest could also be a causa ve factor. Inves ga on into the incidences would be required to make this determina on. Legally, billing fraud can have consequences for the individual and the hospital that employs him. "Prosecu on for fraud and abuse can lead to civil (monetary) penal es (including triple damages) for each claim or service, and in some cases, criminal penal es," (Mackey, et al. 2020). Many legal laws and regula ons have been designed to combat fraud including the False Claims Act, the An kickback statute, the Stark law, the Exclusion status, and the Civil Monetary Penalty Law (Mackey, et al. 2020). Depending on the severity of the specialist's infrac ons, penal es could include nes versus jailtt me.
The manager should begin by addressing the issue with the individual and forgoing his future workload to prevent recurrence on future accounts. Juxtaposing, the manager should involve a highertt up versed in the inves ga on of fraud or abuse of the healthcare system. Inves ga on into the incidents should include examples of noncompliance with standards, inves ga on into all accounts handled by the individual, and interviews to determine the intent. Based on this, if it is solely the individual and not a systems error, repor ng to the proper means is necessary and likely the billing specialist will be terminated. If a lack of educa on is the causa ve factor, remedia on is needed, and the accounts and sta will need to be audited to ensure accurate training.
Mistakes are inevitable and individuals with their own agendas are also inevitable. Addressing these issues at point of contact and further reassessing are necessary t