BHAFPX 4006 CU How Healthcare Fraud and Abuse Affects the Healthcare Industry Paper

Attached. Please let me know if you have any questions or need revisions.Running Head: FRAUD AND ABUSE IN THE HEALTHCARE SECTORFRAUD AND ABUSE IN THE HEALTHCARE SECTORBy, (Name)Course)ProfessorInstitution AffiliationDate1FRAUD AND ABUSE IN THE HEALTHACRE SECTORThesis Statement: There exist rampant cases of healthcare fraud and abuses in the healthcareindustry.I. Research Models on the effect of prescription drug abuse in Americaa. Qualitative and quantitative research methodsb. Case studies, cross-sectional studies, observational studies, and surveysII. Research model compatibilitya. Qualitative research method through convenient samplingb. The researcher focused on getting information from the internet to complete the studyIII. Types of healthcare frauda) Kickbacksb) Upcodingc) Identity Fraudd) Falsifying informatione) UnbundlingIV. Healthcare fraud and abuse lawsa) California Penal Code 549PCb) Nevada False Claim Actc) Federal False Claim Actd) The Stark Lawe) Anti-Kickback Statutef) The rationale for applying the lawsV. Upcoding and the Lawa) Punishable under the False Claim and Act LawsVI. How Upcoding happens in HospitalsVII. Recommendations to Prevent Upcodinga)Hire professionalsb) Use the Right toolsc) Use Caution with EHRsVIII.Conclusiona) Healthcare fraud and abuse is expected in the healthcare sectorb) There exist various healthcare fraud and abusec) There exist various federal and state laws meant to prevent or minimize healthcare fraud2Running Head: FRAUD AND ABUSE IN THE HEALTHCARE SECTORFRAUD AND ABUSE IN THE HEALTHCARE SECTORBy, (Name)Course)ProfessorInstitution AffiliationDate1FRAUD AND ABUSE IN THE HEALTHACRE SECTOR2IntroductionThe healthcare industry, over the years, has experienced fraud and abuse at the mostdisheartening rate forcing legal, technological, and healthcare experts to come up with policiesand laws aimed at curbing the malpractice. Despite laws that aim to prevent fraud and abuse inthe healthcare sector, fraud cases are still prevalent in different healthcare organizations acrossthe United States. Kickbacks, failure to accurately charge Medicaid and Medicare patients, andupcoding are just a few of the very many fraud and abuse cases that happen the most inhealthcare organizations. Therefore, healthcare institutions must establish programs aimed atcurbing abuse and fraud in the healthcare sector. According to the National Conference of StateLegislatures, NCSL, (2017), programs meant to control healthcare fraud and abuse get designedto prevent, identify and prosecute individuals implicated in unlawful billings. This paperdiscusses fraud and abuse in the healthcare industry, recommending ways to prevent, identifyand prosecute individuals found practicing illegal billings such as up-coding.Types of Healthcare Fraud and AbuseThere exist various categories of healthcare fraud and abuse. The most common types ofhealthcare frauds and abuses include; up-coding, kickbacks, unbundling, billing for services notfurnished, and identity fraud (Center for Medicare and Medicaid Services, CMS, 2021). It is vitalto note that these types of medical frauds and abuses get accomplished by healthcare providers,doctors, or patients. Formulation of laws and technology to prevent and identify healthcarefrauds should target all individuals, whether patients or healthcare providers, who engage inunlawful practices to increase profits or get services using the wrong procedures.FRAUD AND ABUSE IN THE HEALTHACRE SECTOR3KickbacksFraud involving kickbacks is the most discussed type of malpractice carried out in mosthealthcare organizations across the United States. CMS (2021) states that kickbacks involvesoliciting, offering, or paying for beneficiary referrals for medical items or services. An exampleof a kickback is for an individual to receive payment from a doctor or a healthcare provider forreferring individuals for medical services. Furthermore, a pharmacist may opt to prescribe aspecific drug to a patient instead of another medicine to benefit a particular pharmaceuticalcompany. Physicians can also receive kickbacks by prescribing illegal drugs for easieraccessibility to particular individuals. However, it is essential to note that receiving kickbacks toprescribe particular medications to patients can be detrimental to their health.Identity FraudFraud involving identity occurs when an uninsured person assumes the person’s identitywith the insurance cover to hide particular illnesses of getting services. CMS (2021) outlines thatdoctors may unknowingly provide medical services and claim reimbursement for another personother than the insurance cover owner. Identity fraud can also happen under the card owner’sknowledge or without the owner of the cover knowing. In America, millions of dollars get lostthrough fraud related to identity. Therefore, there is a need for organizations such as Vilahealthcare institutions to establish means to prevent or minimize fraud cases within thehealthcare sector.UnbundlingUnbundling is a healthcare fraud that involves billing for multiple codes for severalprocedures paid in a single billing code. The scam involves establishing separate claims forsupplies or services that should get grouped (CMS, 2O21). However, the technology is known asFRAUD AND ABUSE IN THE HEALTHACRE SECTOR4″Grouper” has helped prevent unbundling as a form of fraud in the healthcare system by rejectingunbundled claims or re-bundle the claims and adjusting the payment in one single code. Thanksto technology, this type of frauds is not as common as one would expect in the absence oftechnology. Unbundling is therefore easily detected, unlike kickbacks and up-coding, whichpresent more challenges in detecting and persecuting the culprits. Many hope that as technologyadvances, more healthcare frauds and abuse will decline drastically due to technology integrationinto the healthcare sector.Billing for Services not providedBilling for services not furnished is another form of healthcare fraud common inhealthcare institutions. The scam involves intentionally billing for medical services or medicinesnot offered to the patient. Billing for services not provided is a concept that gets also referred toas phantom billing. Most hospitals submit claims to insurance companies, Medicare, Medicaid,and TRICARE, intending to solicit and claim funds for services not offered to patients.According to the FBI (2021), the U.S government strives to identify and pursue investigationsagainst healthcare fraud individuals. The inspector general’s office plays a vital role ininvestigating and identifying the culprits involved in healthcare fraud and abuse.Up-codingLastly, up-coding wraps up as another widespread healthcare fraud that peopleexperience in the health care industry. Up-coding refers to a fraud in the medical sector in whicha billing that gets prepared and delivered for service is quite expensive than it should cost basedon the actual situation. Up-coding perhaps is the most common healthcare fraud and abuse thathappens in most healthcare institutions. It is easier for healthcare providers to carry out this kindof fraud since analyzing costs of patient reviews and procedures lies solely within theirFRAUD AND ABUSE IN THE HEALTHACRE SECTOR5description. CMS (2021) describes Up-coding fraud as one that involves billing for services ormedicines at a prohibitive price than required. One can send an up-coded billing to any payer,including; Medicaid, private health insurer, the patient, or Medicare. The FBI collaborates withlocal, State, and Federal Agencies, associations, private insurance companies, and investigativeunits to prevent up-coding and other healthcare frauds and abuses in America.Health Care Fraud and Abuse LawsThe rampant spread of fraud and abuses in the healthcare industry has prompted legalexperts in the United States to formulate laws meant to prevent, detect and prosecute individualsinvolved in fraud and abuses. The United States government loses billions of dollars tohealthcare-related frauds and abuses. Bonnell (2016) narrates that in the year 2014, the nationalhealthcare budget was over $3Trillion, and about 3% to 10% of the healthcare budget nationallygot lost through healthcare fraud and abuses. Therefore, it is evident that America stillexperiences healthcare fraud and abuses at a shocking rate despite numerous laws and policies.The country has established some of the most progressive laws to curb fraud in hospitals.However, in addition to the rules, a lot needs to get done to streamline the healthcare industry.Some of the laws established to prevent, detect and prosecute individuals who engage inhealthcare malpractices by States and Federal government include;California’s Penal Code 549 PCIn California, healthcare fraud gets also referred to as healthcare insurance fraud,Medicare, or MediCal fraud. The increasing cases of fraud prompted California’s Stategovernment to establish laws to prevent or minimize healthcare fraud and abuse. According toShouse California Law Group, SCLG, (2021), Penal Code 549 PC is one of California’s statutesthat proh…

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