Individual Paper
The following deliverables are required for the Individual Paper requirement.
Week 4
Work on your Individual Paper. You should have the Background, Problem Statement, and Literature Review sections of your individual paper complete—two to three pages, double-spaced.
Week 5
Continue work on your individual Paper. You should have the Analysis of the Problem and Recommendations/Solutions sections of your paper complete—three to four pages, double-spaced.
Week 6
Continue work on your individual Paper. You should have the Implementation Plan, Introduction, Conclusion with Future Recommendations, and References sections of your paper complete—three to four pages, double-spaced.
Healthcare fraud is something that has increased over the years. Due to the False Claims Act of 1863 and the improvement in technology, more organizations and physicians are being held accountable for committing this act. At the same time, more whistleblowers are also coming forward with their findings. Types of healthcare fraud are the following:
Analysis of the Problem
? Billing for the same service more than once
? Billing for a service never rendered or a durable equipment never received
? Billing for a service separate from what the patient was provided to receive more money
? Using someone else’s insurance or letting someone use your insurance
? Acting as a medical professional without a license
? Fraudulent prescriptions
You would think committing fraud within children’s healthcare would be frowned upon, but a thief has no bounds. “Hospitals and medical facilities were the most-frequent subjects investigated in civil fraud cases, including cases that resulted in judgments or settlements.
A.) Subjects of criminal cases: Many of the 7,848 criminal subjects in 2010 were medical
facilities or durable medical equipment suppliers, representing about 40 percent of subjects
of criminal cases. Similarly, in 2005, medical facilities and durable medical equipment
Analysis of the
Problem
cont.…
suppliers accounted for 41 percent of criminal case subjects. Data from 2010 show that most
of the subjects were in cases that were not referred by HHS-OIG to DOJ for prosecution (85
percent). Of the subjects whose cases were pursued, most were found guilty or pled guilty or
no contest.
B.) Subjects of civil cases: Over one-third of the 2,339 subjects of civil cases in 2010 were
hospitals and medical facilities. In 2010, about 35 percent more subjects were investigated in
civil fraud cases than in 2005. Half of the subjects’ of 2010 cases were pursued. Among the
subjects whose cases were pursued, 55 percent resulted in judgments or settlements”
(https://www.gao.gov/products/gao-12-820).
One example of fraud in children’s healthcare took place last year in the state of New
York. A nurse practitioner who was the owner of a pediatrics center fraudulently
signed COVID-19 vaccination cards without administering the vaccine. She charged
$85 per child, as well as a fee for adults. One of her patients ended up being an
undercover police officer, and they were given a fake card as well. Once their
Analysis of the
Problem
cont.…
information was registered in the New York State Immunization Information System
(NYIIS), her scheme was shut down. A few of her staff members including herself
were arrested and held accountable for their crimes.
Keep in mind, there is one form of fraud that doesn’t get spoken of much and that is
overpayments. There are times insurance companies may overpay the healthcare
provider unintentionally. But it is the duty of that healthcare provider to return those
extra funds. By not returning them, this can be considered fraud or theft. Due to
payment guidelines, providers are already aware of their reimbursement rate so
receiving anything higher than that is an issue.