Healthcare Compliance Case Study

Identify theft, in general, can affect a person for a lifetime. Federal law defines medical identity theft as “A fraud committed or attempted using the identifying information of another person without authority to obtain medical services or goods, or when someone uses the person’s identity to obtain money by falsifying claims for medical services and falsifying medical records to support those claims.” (“Red Flag Rule - Identity Theft Prevention Policy”, 2009). However, medical identity theft is not as easily traced compared to something such as, credit card theft. With the crime being less traceable and the ever-expanding health care system, it is not surprising that medical identity theft is continually rising. Medical identity theft accounts

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.

A. Discuss how you would carry out your various responsibilities as a coding manager by doing the following:

     On September 24, 2010, a laptop was stolen from an unlocked Urology office at the Henry Ford Health Systems hospital. The laptop did contain password protection software; however, it may not have been enough to permit access if the thief had advanced knowledge in computers. Additionally, the information stored on the laptop did not include social security or health insurance information, but instead held “patient names, medical record numbers, dates of birth, telephone numbers, e-mail addresses, and treatment and doctor visits” (Moscaritolo, 2010, p. 1). It is unknown how many records were contained on the laptop, but all records were related to prostate services that were provided during an eleven year span.

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

Health insurance fraud is what drives up health insurance premium costs, wastes taxpayer’s money, but can also endanger beneficiaries or leave them uninsurable. In 2015, Medicare Strike Force reported over $700 million in false billing by doctors, nurses, other licenses medical professionals, laboratories, and individuals (FBI.gov). This is a staggering figure that is only getting worse. In this fictitious federal case I will be describing the criminal offender, the crime that was committed, the charge handed down by law enforcement, and the judicial process from the beginning of the criminal case to the sentencing of Dr. Richard Heartman, an internal medicine physician.

Jordan was arrested, she had the credit card information of over 200 patients and the identify profile of over 400 patients. She was charged with 21 counts of Identity theft and 3 counts of multiple identifying information theft, and could face up to 19 years in county jail if convicted. She is accused of misusing the credit cards to purchase products for personal use.

This booklet is designed to serve as a guidance to concepts of fraud and abuse laws which affect the coding, claims management, charge master and bill reconciliation. It is important to understand the laws as a variety of health care providers’ payment and arrangement activities are prone to fraud which eventually result in criminal penalties and unethical behaviors in health services. To evade associated liabilities, employees should understand the fraud and abuse laws and compliance policies.

There would be multilevel of HIPAA training with presentations, online training material, and a frequently asked questions page. The live presentation will be mandatory for all current medical staff and new hires. The online training would be a refresher course given out every year, with a quiz at the end. A frequently asked question page would be available all year long on the intranet and updated as needed.

Identity theft can be divided into several categories and, unfortunately, this fast growing crime already reached our medical records. This kind of identity theft, classified as medical identity theft, can easily be done because there are also several persons, whether authorized or unauthorized, who can access our medical records that contains necessary and confidential information. These people can be anyone, from physicians to other medical personnel or even some other persons who really want your medical identity.

Rising costs of healthcare is a valid concern for many households in America. A factor in the cost of healthcare insurance is fraud. Fraud is often very difficult to detect. The magnitude of healthcare fraud is unknown. Initial reimbursement and payment and billing timeframe of 90 days allows for fast payment of services, however, many times before there is an indication of fraudulent billing the company has closed up and moved on. Fraud in American healthcare, costs American’s millions perhaps even billions of dollars annually. Without doubt, behind every act of fraud lies a lapse in ethics. This paper will review several pieces of literature to look

The document will explain how unethical and disturbing her behavior was by falsifying a patient information and the document should further highlight additional corrective actions that may be taken if she were to repeat this act. In addition, she should receive additional training in the policies and requirements for providing accurate medical data, the legal perspectives of employee responsibilities, and consequences for employee misconduct. Plus, an investigation should be opened up in the matter to evaluate Ms. Smith entire performance for that day and whether she might have falsified patient data previously in other situations. This procedure may unravel potential issues that can pose harm for the organization in 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.

Medical identify theft is the biggest challenges face by both health care organization and patient. It is the practice in which someone uses another individual’s identifying information such as health insurance information, SSN, address, phone number and other personal information without individual knowledge or permission to obtain medial services, goods or to obtain money by falsifying claims for medical service and falsifying medical records to support those claims ( Mancini, 2014). Healthcare organization, Providers, insurance payers and patient are negatively affect by the medical identity theft. Among them, Patient are the biggest victims because they are the one who will receive unwanted treatment and medication which may be life threatening,

These crooks are the possible cause of ruining the reputation of the most trusted and appreciated professionals of our society – physicians. Healthcare fraud can be committed in a variety of ways, but three of the most widely used are described below. The first and most widely known, is billing services that were never endured by using general patient information. When giving personal information out, many hand it over to the front desk assistant at the local doctor. These appear to be people are some of the most known to scam the information and bill patient’s payments that never took place. Keep in mind that when handing over information, the handler is a trusted individual with a good reputation. On the other hand, many are scammed for the opposite; otherwise known as “upcoding,” where patients are billed more expensive services that were actually done. In fact, according to USA.gov a new study showed that 7 percent of identity fraud victims this year reported identity thieves stole their health insurance information, rising up from just 3 percent last year (Federal Bureau Investigation, 2010). This includes the latest scam, called “unbundling,” where scammers con bills and bill each step of a procedure as if it were a separate making the individual pay even more money, leaving devastating effects for the victim. All of which have a common goal of making taxpayers, insurance companies, and