Assignment 2: The Financial Aspects Of Medical Coding

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

“Individuals who would like to become a certified medical coder must pass examinations offered by the American Health Information Management Association (AHIMA) and the American Academy of Professional Coders (AAPC) (Medical Coding Specialist, 2002-2004).”

Health care fraud comes from many aspects. Fraud comes from some type of abuse to the system. Such abuse can come from billers, providers and or patients. Abuse of the system can turn into fraud. Because the fraud can come from many angles, it makes it really difficult for regulatory agencies to detect and protect against abuse and fraud. However, many changes to the system and the collaboration of regulations by many agencies have made a difference. Health care fraud is a crime that over time has had a significant impact on public and private health care payment system (Kongstvedt, 2013). Making a difference for this topic can have a significant impact on health care in general. Health care fraud takes a lot of means from the system, therefore affecting its goals. Not only does it distract the system from its objective, it also affects the financial status of the government. It takes a lot of effort to control fraud, economic effort that can otherwise be use in other struggles. Because this industry is one that grows with popularity, it is very difficult for only one organization to control or manage abuse or fraud. Popularity in this field brings great financial gains by those who choose to cheat or abuse the system. Above all, one must continue to make efforts to fight back and to control the losses caused by fraud. In order to continue these efforts, one must first understand how much is lost by these criminal acts. Therefore, this paper will focus on one

Fraud and abuse encompasses the actions of fraud, abuse, and waste in the health care system (McWay, 2014). It is a nationwide problem that affects all of us and can be committed by anyone. Schemes can be committed by a single person or a by an institution or group. The National Health Care Anti-Fraud Association (NHCAA) estimates that

Some estimate that the federal government loses 30 percent of every dollar it spends on medical claims, due to medical billing mistakes and fraud. With so many loopholes and regulations surrounding Medicare, it is impossible for one person to know every nuance. However, constant diligence and ethical practices are a cornerstone of catching and preventing medical billing mistakes.

It is easy to see how fraudulent medical billing is having a major impact on the Unites States and the citizens of this country who rely on it on a daily basis. We often hear through the various new sources in this country, on the internet or out of the mouths of politicians and experts in the healthcare field about the failing healthcare system in this country. We often hear many different opinions on what needs to be done to fix our healthcare problem within this country and fix what looks to be a very broken system at this point. No matter what the solution to our poor healthcare system is one thing that is very clear is that healthcare fraud and abuse is playing a major role in the depletion of money in this country and the rise in healthcare costs for the citizens of this country.

Fraud is a serious crime that should concern all parties of the U.S. health care system and is a costly reality that the government cannot overlook. While not all fraud can be prevented, by learning about the many different types of fraud, patients can be educated on how to protect themselves from fraud. If we use government programs to inform the public that they can be targeted, the dollar amount for these cases for fraud can be reduced. An informed public and a properly funded FBI will go a long ways in the overall crackdown of health care fraud.

The EHRs have an automated system which may result in a suggested E/M code. Coders have to make sure this code is accurate because the clinicians are responsible for the submission of this code for the reimbursement of the facility. If the code is accurate then it could result in an increase up to tens of thousands of dollars in revenue. The common pitfalls of coding E/M services are down coding the level of care that is given to the patient. They do this because they are afraid of the risk because they do not know what code they are actually supposed to use and it is their natural instinct to do so. They don’t think about the documents that support what they have done. Another thing that is done is tied to the level of complexity of the visit. The hardest part of not knowing which code to pick is the medical decision making because it is not always so easy to pick out and hard to express in writing. Documentation is crucial to figuring out the code. If it is incomplete then the coder cannot properly decide which code to use. The doctors don’t usually think about writing the complexity of the visit, they forget to put in specific things like the images they have reviewed and the info gathered from people other than the patient. One other than that can happen is that the EHR will generate a code through the E/M calculator and it may generate one that causes an upcoding incident.

Fraud and waste of resources allocated for Medicare pose major risks to the program. Medicare is very vulnerable to a number of frauds majorly due to the fact that the program is hardly audited. Medicare scams occur in various ways that include phantom billing where healthcare providers demand money from Medicare for services not offered. The other form of fraud happens in the shape of patient billing where the patients collude with scammers to claim for kickbacks for false medical treatments. The last type of fraud is the upcoding scheme and unbundling, where bills are inflated by claiming that a patient needs more valuable services or procedures than the existing. The government has been sensitizing the general public on the need to avoid such frauds by not disclosing their Medicare card details to

Now in 2015, healthcare fraud and abuse was getting to an all time high and now more situations were being committed such as phantom billing,false patient billing, upcoding and upbiling. Now several federal agencies had come together to eliminate several occurrences pertaining to this matter. The outcome to really crack down on this matter is when the U.S. government created the Health Care Fraud Prevention

As we head into the next four years under the Obama administration, many Americans are hearing more and more about healthcare reform and what needs to be done to fix the ailing healthcare system. Part of the dramatic increase in healthcare costs is due to Medicare fraud abuse. Healthcare fraud is defined as making false statements or representations of material facts in order to obtain benefits or payment. Healthcare abuse is defined as practices involving the overuse or misuse of services, either accidentally or intentionally, for various reasons that results in overpayment. These acts may be committed by an individual person or an entity. Fraud and abuse exposes a person, provider, or entity to criminal and

Although Congress has used several anti-fraud measures to protect the federal government health care programs, the False Claims Act of 1986 has become the main weapon that government prosecutors use against perpetrators of health care fraud. Designed to prevent fraud and other abuses in federal government programs, the False Claims Act has been the primary statute the government has used in its fight against health care fraud. However, government prosecutors do not rely on one statute in their prosecution of alleged cases of health care fraud. Instead, they rely on a combination of statutes, but the False Claims Act has emerged as the main statutory weapon.

Another effective way of controlling healthcare fraud and abuse is through reinforcement of federal penalties, enforced by the department of Health and Human Services. For example, in the year 2011, the US department of Health and Human Services committed approximately $248 million in the fight against fraud and abuse. This extraordinary effort resulted in a significant increase in the number of cases prosecuted, amount of money recovered, and the dollar amount of claims filed. The federal government can assist healthcare overall fight the abuse and fraud by being assiduous in prosecuting the providers, the healthcare organizations, and individuals who commit fraud and abuse in an organized and systematic manner, not sparing anyone, because

According to a report obtained by the National Health Care Anti-Fraud Association (NHCAA), in the year 2011 alone, approximately $2.27 trillion was spent on health care and more than four billion health insurance claims were processed in the United States. From just this report alone, we can see that is an undisputed reality that some of these health insurance claims are fraudulent. Although they constitute only a small fraction, those fraudulent claims carry a very high price tag in the end. Health care fraud is a national problem, prevalent in federal and state as well as private insurance programs. From information that the U.S Department of Health and Human Services tells us in this area, it appears that

Insurance companies and the federal government should pool resources using a percentage of profits to finance a task force to arrestively fight fraud. The penalty for fraud should be more stringent which will cause perpetrators to think twice before formulating a plan to commit fraud. The Affordable Health Care Act is the beginning of many programs established to fight against fraud. Health care fraud is a growing problem and should be taken more seriously by citizens of the United States. Physicians, health care workers, and patients are responsible for