Title: Impact of Compliance Plans on Physician Fraud

Subject: Advanced Health Information Law and Ethics

Title: Impact of Compliance Plans on Physician Fraud

Select a case involving physician healthcare fraud, and using APA format in a paper no longer than two pages, provide a brief summary of the case. Identify the statute, rule, regulation or law that the physician violated or allegedly violated (ie. Federal Anti-Kickback statute, False Claims Act) and how the fraud was identified. Recommend how a more stringent compliance plan at the healthcare organization could have detected and or prevented the fraud. Support your recommendations by providing which of the steps in effective compliance program would have best addressed the issue, based on your readings from the module.

Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates.

Week 9 Rubric and Lesson Content

Scoring Rubric: Module 10 Written Assignment- Impact of Compliance Plans on Physician Fraud

Criteria 1 Physician healthcare fraud case selected15
Criteria 2 Identified correctly the statute, rule, regulation or law the was allegedly violated15
Criteria 3 Recommendation of how compliance plan could have detected/prevented the fraud15
Criteria 4 Recommendation supported by identification of step(s) in compliance plan which address the issue15
Criteria 5 Maximum of two page paper in APA format with sources cited

The federal government has initiated efforts to investigate healthcare fraud and to establish guidelines to ensure corporate compliance with the government guidelines. Part of the initiative involved providing healthcare organizations with guidelines for developing comprehensive compliance programs with specific policies and procedures.

Probably the most pertinent fact in the history of corporate compliance related to healthcare organizations is that the federal government, specifically the HHS, is the largest purchaser of healthcare in the United States. Because one of the federal government’s duties is to use the taxpayers’ monies wisely, federal agencies must ensure that the healthcare provided to enrollees in federal healthcare programs is both appropriate and is actually provided.

Several federal initiatives and pieces of legislation related to investigating, identifying, and preventing healthcare fraud and abuse have been passed. Interestingly, the basis of these initiatives and laws lies within the Civil False Claims Act. Several government agencies are involved in detecting, prosecuting, and preventing fraud and abuse. Among them are the HHS, the Office of the Inspector General (OIG), the Department of Justice (the attorney general), the Federal Bureau of Investigation (FBI), and Center for Medicare and Medicaid Services (CMS).

In February 23, 1998 Federal Register, the OIG outlined seven elements as the minimum necessary for a comprehensive compliance program:

  • The development and distribution of written standards of conduct, as well as written policies and procedures that promote the hospital’s commitment to compliance
  • Designation of a chief compliance office
  • The development & implementation of regular, effective education and training programs for employees
  • The maintenance of a process, such as a hotline, to receive complaints
  • The development of a system to respond to allegations of improper or illegal activities and enforcement of disciplinary action
  • The use of audits or other evaluation techniques to monitor compliance
  • The investigation and remediation of identified systemic problems and development of policies

The OIG believes that a compliance program conforming to these elements above will not only “fulfill the organization’s legal duty to ensure that it is not submitting false or inaccurate claims to government and private payers,” but will also result in additional potential benefits.

From its very beginnings, financial reimbursement for healthcare services has followed several paths. Among these are private pay, commercial insurance, employer self-insurance, and various government programs. The mixture of payment mechanisms has made healthcare reimbursement in the United States very complex.

As a consequence, the processing of medical claims can be complicated. How a claim is processed, what documentation is required, and how much reimbursement will be paid depend on the payer and the type of claim. Many attempts have been made to create a uniform healthcare claim that would accommodate all payment mechanisms. Claims processed for payment under Medicare have been consolidated into a uniform bill.

The following PowerPoint presentation will guide your note taking as you explore the key concepts related to Corporate Compliance.

Fundamentals of Laws for HI and IM, Chapter 15

Additional Resources

AHIMA Practice Brief “Guidelines for EHR Documentation to Prevent Fraud. Appendix C: Steps to Prevent Fraud in EHR Documentation”

Whistleblower Protections

Court Rulings Protect Whistleblowers from Retaliatory Actions

Medical Fraud and Abuse

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