Jan 12, 2018 sample paper

What is the purpose of a Compliance Program?

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Review below on Title II and
Healthcare Fraud and Abuse information and answer the following questions:

  • What is a false claim?
  • Are mistakes and errors
    considered to be fraudulent behavior?
  • What is the purpose of a
    Compliance Program?
  • There are seven steps to the
    compliance program. Think about your role in insurance billing. Describe
    the steps where you will be able to have the greatest impact to help avoid
    creating erroneous and fraudulent claims. What are some best practices you
    could implement within these steps to ensure you are adhering to Title II?

Require in 150 words APA format,
reference search via website.


Title II—Preventing Health Care Fraud and Abuse

HIPAA defines.vitalsource.com/books/9781285011967/content/id/ch05-P34″>fraud as “an intentional
deception or misrepresentation that someone makes, knowing it is false, that
could result in an unauthorized payment.” The attempt itself is considered
fraud, regardless of whether it is successful..vitalsource.com/books/9781285011967/content/id/ch05-P11″>Abuse “involves actions that
are inconsistent with accepted, sound medical, business, or fiscal practices.
Abuse directly or indirectly results in unnecessary costs to the program
through improper payments.” The difference between fraud and abuse (.vitalsource.com/books/9781285011967/content/id/T19″>Table 5-2) is the individual’s
intent; however, both have the same impact in that they steal valuable
resources from the healthcare industry.

When a Medicare provider commits fraud, an
investigation is conducted by the Department of Health and Human Services
(DHHS) Office of the Inspector General (OIG). The OIG Office of Investigations
prepares the case for referral to the Department of Justice for criminal and/or
civil prosecution. A person found guilty of Medicare fraud faces criminal,
civil, and/or administrative sanction penalties, including:

• Civil penalties of
$20,000 per false claim plus triple damages under the False Claims Act. (The
provider pays an amount equal to three times the claim submitted, in addition
to the civil penalties fine.)

• Criminal fines
and/or imprisonment of up to 10 years if convicted of the crime of healthcare
fraud as outlined in HIPAA or, for violations of the Medicare/Medicaid
Anti-Kickback Statute, imprisonment of up to 10 years and/or a criminal penalty
fine of up to $100,000.

• Administrative
sanctions, including up to a $20,000 civil monetary penalty per line item on a
false claim, assessments of up to triple the amount falsely claimed, and/or
exclusion from participation in Medicare and state healthcare programs.

In addition to these penalties, those who
commit healthcare fraud can also be tried for mail and wire fraud.

TABLE 5-2 Fraud and abuse
examples and possible outcomes



• Accepting or soliciting bribes,
kickbacks, and/or rebates

• Altering claims to increase

• Billing for services or supplies
not provided

• Misrepresenting codes to justify
payment (e.g., upcoding)

• Entering a health insurance
identification number other than the patient’s to ensure reimbursement

• Falsifying certificates of medical
necessity, plans of treatment, and/or patient records to justify payment

• Administrative sanctions

• Civil monetary penalties

• Exclusion from the health program
(e.g., Medicare)

• Referral to the Office of Inspector

o • Exclusion from
Medicare program

o • Sanctions and
civil monetary penalties

o • Criminal
penalties (e.g., fines, incarceration, loss of license to practice,
restitution, seizure of assets)



• Billing noncovered services as
covered services

• Billing or claim processing errors

• Duplicative charges on a claim

• Excessive charges for services,
equipment, and/or supplies

• Improper billing practices that
result in payment by a government program when another payer is responsible

• Submitting claims for services not
medically necessary

• Violations of participating
provider agreements with third-party payers

• Education

• Referral for Medical Review

o • Prepayment review
of submitted claims

o • Postpayment
review (audit) of submitted claims

• Recoup overpaid funds

o • Provider refunds

o • Payment is
withheld from future processed claims

o • Suspension of
payer payments (e.g., MAC holds checks)

• Warnings

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