Coding Fraud And Abuse In The Healthcare Industry

The Canadian Health Information Management Association Code of Ethics outlines a powerful standard for Health Information Management Professionals. When one becomes a member of CHIMA along comes the responsibility of following the code of ethics as faithfully and professionally as possible. Although the interpretation of the guidelines can vary among individuals and organizations, the basis and underlying meaning of each code should be synonymous. The ten codes set general expectations for HIM professionals that help the public understand the ethical views of CHIMA. With these ethics in place we are able to decrease the number of breaches, improve data quality and encourage lifelong learning. There are a number of breaches that occur in healthcare settings that go unreported on a daily basis. The reason for these cases going unreported could be the lack of knowledge of severity and consequences, or have a malicious intent. The case study is a definite breach of the CHIMA code of ethics- and could fall into numbers 1-10, but in my opinion is more relevant to numbers 2-3, 5-7 and 9. Jane should have acted in a more proactive manner reflecting CHIMA values and informed the appropriate individuals so that they correct actions could be made.

Health care fraud and abuse are one of the U.S healthcare system biggest problems, which affect everyone either directly or indirectly. Billions of dollars have been lost due to health care fraud and abuse. With a number of losses, this can lead to increase in health care costs and potential increased of coverage.

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.

Title II of HIPAA covers two main areas: preventing healthcare fraud and abuse, and a broad series of rules under the framework of administrative simplification. The first area is not of significant interest to most healthcare workers. It defines numerous offenses relating to healthcare, and authorizes several programs to attempt to find and control fraud and abuse. Nurses should be aware of the proper procedures for reporting fraud and abuse at their facility. The second portion of Title II—administrative simplification—however, contains five separate rules, most of which have already had a significant impact on virtually everyone working in American health care, including all those working in any way with health information concerning

As mentioned in my discussion, Health Information Coding Supervisors are trusted individuals who have access to an organization’s highly confidential security system. A misrepresentation of this position can lead to significant consequences because of the Health Insurance Portability and Accountability Act (Prophet, 2015). Criminal penalties imposed on individuals who knowingly and willfully attempt to execute a scheme to defraud any health care benefit program can be up to 10 years imprisonment and possibly life imprisonment depending on the circumstances. Civil monetary penalties can lead to $2000 to $10,000 for each fraudulent payment received.

For purposes of the Statement, fraud is an intentional act that results in a material

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

The Standards of Ethical Coding are based on the American Health Information Management Association 's (AHIMA 's) Code of Ethics. Both sets of philosophies show what the expectations of practiced conduct for coding is for professionals involved in diagnostic and/or procedural coding or other health record data (AHIMA House of Delegates) . In any area of the healthcare field, you must be careful to remain ethical at all times. Even when you are at home. You can’t just talk about patients. We all know that saying “What happens in Vegas, stays in Vegas.” It is the same concept in the workplace. “What happens in the workplace stays in the workplace.”

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

The physician marks the E&M code on the encounter form and the medical assistant will ensure that the documentation in the medical record matches the codes that are checked off. Whenever a medical assistant is unsure about a coding or billing issue the best way to handle the situation is to speak with the physician or reach out to their supervisor or a certified coder. Incorrect coding could lead to denial or delay of insurance claims and it could also lead to fraud or abuse. If I were Lisa’s medical assistant in this situation I believe the best option is to speak with Dr. Parker about the issue. One of the reasons I would speak with him about the issue is because it is unusual for him to check off diabetes unspecified for most of his patients

2. Made with knowladge of its misrepresentation or without adequate information on the subject to warrant a representation,

In today’s health care industry providing quality patient care and avoiding harm are the foundations of ethical practices. However, many health care professionals are not meeting the guidelines or expectations of the American College of Healthcare Executives (ACHE) or obeying the organizations code of ethics policies, especially with the use of electronic medical records (EMR). Many patients fear that their personal health information (PHI) will be disclosed by hackers or unauthorized users. According to Carel (2010) “ethical concerns shroud the

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.

Fraud is defined as a deliberate misrepresentation that causes a person or business to suffer damages, often in the form of monetary losses through deception or concealment. And Occupational Fraud as defined by the ACFE is the use of one’s occupation for personal enrichment through the deliberate misuse or misapplication of the employing organization’s resources or assets. Traditional fraud triangle theory by Donald Cressey explains that propensity of fraud occurring in an organization lies on three critical elements which are Pressure, Opportunity, and Rationalization.