Health Care Fraud Case Study

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"Insurance companies and other healthcare corporations responded rapidly and aggressively, developing and marketing new models of healthcare delivery. The evolution of these models, collectively referred to as managed care, is changing the American healthcare system." (Vines-Allen 53) As a health care organization entering into a managed care insurance contract is it important for not only the provider but for the medical office specialist to be familiar with all aspects of the contract. Knowing the policies and procedures for submitting claims including covered services, the appropriate claim forms and the time frame in which a claim can be submitted is essential for the medical office specialist or billing specialist to submit a correct claim and to receive full reimbursement. As we have discussed in class, the most common types of insurance payments are …show more content…

In addition the contract should include the coordination of benefits and the guidelines in which a provider can bill a patient for services rendered. ”Health care fraud costs the country tens of billions of dollars a year. It’s a rising threat, with national health care expenditures estimated to exceed $3 trillion in 2014 and spending continuing to outpace inflation. “(FBI) All of the details of a contract can be overwhelming but critical for the medical office specialist who is submitting claims to understand what fraudulent billing looks like and uphold their standard of ethics. But what constitutes fraudulent billing? Billing can become fraudulent in multiple ways. Billing for a service that was not provided is fraud. Upcoding a service that was provided which means that a service provided was coded for

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