Reimbursement In Healthcare

Fraud is defined as the intentional deception or misrepresentation of facts that can result in unauthorized benefit or payment. Abuse is

It is important to follow payer guidelines when completing a claim form; otherwise, reimbursement will be delayed until the form is corrected.

Unit 2 AssignmentKelley WhitcombKaplan UniversityHI215-01: Reimbursement MethodologiesProfessor Kathleen SobelJuly 20, 2015Medicaid is one of the biggest insurance plans you can get in any state. In the state of Indiana, it is based off of your income. There is a certain amount (income) you have to make to determine if you will receive Medicaid or Healthy Indiana Plan (HIP). HIP is still a form of Medicaid, but you would have to pay monthly cost for it and have certain set of co-pays for certain services that is needed. HIP Plus is the recommended plan for members as it provides health coverage for a low, predictable monthly cost. HIP Plus also covers dental and vision services. If you do not pay your monthly payment you can be removed from

When providers or patients submit false or misleading information intentionally to a health plan, this is fraud. Some examples of healthcare fraud and abuse include filing claims for services or medications not actually performed or obtained, billing for services for non-covered items using codes for billable services or items, altering medical records, waiving co-pays and deductibles, up coding and unbundling, using someone’s insurance card, billing Medicare patients at a higher fee than non-Medicare patients, and accepting kickbacks for referring patients, to name just a few. Fraud can be committed by hospitals, medical providers, laboratories, pharmacists, billing services, medical equipment suppliers, and even patients. Patients can protect themselves from healthcare fraud and abuse by knowing their healthcare benefits, reviewing the explanation of benefits, asking the doctor to explain the service that was given, report discrepancies, protect insurance cards and member identification numbers, beware of free services, report copayment and deductibles being waived, and never sign blank insurance forms.

The goal of this deception is to obtain a federal healthcare payment that would not otherwise exist. The provider, practice, or institution may falsely claim to have provided a service or used supplies for a patient when in reality neither the service nor the supplies were used. A secondary way to commit Medicare fraud involves referrals. If one solicits, pays, or accepts money to encourage referrals because the services are reimbursed by Federal healthcare programs, they are participating in Medicare fraud. This type of fraud is addressed in the Anti-Kickback Statute. Lastly, Medicare fraud occurs when the complexity of services are overstated and billed at a higher than necessary rate. This action violates the False Claims Act which protects the government from being excessively charged for goods and services.

Before the Obamacare, many individuals had no medical insurance. A noted author, Amy Anderson state: “Approximated 30 million Americans were anticipated to gain health insurance through the Affordable Care Act (ACA) or Obamacare; a comprehensive healthy workforce would be needed to meet the massive demand”. (Anderson, 2014)

The Affordable Care Act has drastically changed reimbursement (and subsequently patient care) for better and worse. While healthcare has become more accessible, quality of care and doctor-patient interaction has decreased. Statistically, hospitals have seen an improvement in compensation, but this doesn’t include private practice and outpatient centers. Government-run healthcare is slow healthcare, and to make up for this physicians have to work faster and longer. My mom’s work as a physical therapy assistant has her working 10-12 hour days in the off season months of summer, and my own work as a secretary at her office opened my eyes to the consolidation of providers to get better reimbursements, which leads to fewer private practices. While

“The Tax Equity and Fiscal Responsibility Act (TEFRA), signed into law September 3, 1982, mandated the development of a prospective payment methodology for Medicare reimbursement to hospitals.” http://sunlightfoundation.com/blog/2009/09/08/slug/. It changed Medicare reimbursement from a fee for service to prospective payment system. Which is where there`s a reimbursement method where`s there an amount of payment determined in advance of services being performed. The rates are done annually. Reimbursements for inpatient care by a classification scheme called diagnosis-related groups. If the patient might have to stay longer in inpatient care more than average days, the hospital may lose money on that patient.

Healthcare fraud and abuse are different terms that describe different types of deceitful acts done by healthcare professionals or by solo individuals. Fraudulent medical billing is defined as knowingly submitting false statements or making misrepresentations of facts or false documentation to obtain a health care payment. These payments for which no entitlement would otherwise exist, knowingly soliciting, paying, and/or accepting compensation to encourage or reward referrals for items or services reimbursed by federal health care programs and making prohibited referrals for certain designated health services. Fraud healthcare schemes include

Collectively, the Department of Health and Human Services and the Department of Justice work to reduce healthcare fraud and investigate dishonest providers and suppliers. The Health Care Fraud Prevention and Enforcement Action Team recouped almost 3 billion in fraud, this year alone. Also, aggressive strategies exist to eliminate Medicare prescription fraud. Patients abusing or selling painkillers received by visiting several doctors and obtaining multiple prescriptions costs Medicare millions annually. Fraud affects everyone, preventing it requires government officials and citizens diligently working together.

There are several ways that both patients and healthcare providers can commit medicaid fraud. A healthcare provider can commit fraud by billing the insurance company for procedures that were never performed. Some healthcare providers bill people twice for the same procedure, and this is also considered fraud.

How have these laws and policies been used to control fraud, waste, and abuse in federal health care programs?

The increase in individuals acquiring health insurance, due to the Affordable Care Act, causes an increased demand for physicians and physician services (ProCon.org, 2015). As a result of these increases, hospital systems are being face with what is now their biggest challenge, financial burden. The number one financial burden is medical reimbursement. However, stemming from the burden of medical reimbursement, several other challenges are brought forth, such as operating costs and the increased costs for staff, supplies, etc (Ache.org, 2016). Leaders within the hospital setting are having to adjust certain aspects of their operating system in order to keep their hospital systems afloat.

Addressing medical fraud, abuse and waste are the part of improving the healthcare system. In order to prevent these issues in the health care system, patient involvement is most important, they should know their benefits and should always receive the benefit statements. Special monitoring should be conducted to detect the evidence of fraud, abuse and waste and strong punishment should be given to discourage others repeating the similar actions.

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.