Healthcare Fraud and Abuse

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Healthcare Fraud and Abuse 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…show more content…
The CMS plays a role in this collaboration by suspending the payments of suspected fraud schemes (Morris, 2011). There are also special laws in place that help fight against healthcare fraud and abuse. The False Claims Act protects the government from being overcharged or sold less than standard goods or services. The FCA imposes civil liability on a person or entity that submits a fraudulent claim to the federal government. Civil penalties may include fines for up to 3 times the amount of cost in damages to the government for submitting the fraudulent claims (CMS, 2012). The Physician Self-Referral Law or Stark Law prohibits a physician from making a referral for certain health services to an entity in which the physician has a compensation agreement. Civil penalties include fines as well as exclusion from all Federal healthcare programs (CMS, 2012). The Health Care Fraud and Abuse Control Program (HCFAC) was established under the Health Insurance Portability and Accountability Act of 1996. “During the time period from 1997 to 2007, HCFAC collected over $11.2 billion in fraudulent claims, $1.8 billion in 2007 alone” (Rudman, 2009, para.9). The HIM profession plays a big role in controlling healthcare fraud and abuse through monitoring of coding and billing practices in the workplace. There are many auditing programs used to monitor appropriate coding and billing practices in the workplace. The HIM profession can support
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