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2 Q Window Help uny.edu/webapps/blackboard/content/listContent.jsp?course_id=_2236889_1&content_id=_71913 3 8 0 6 9 010 . CASE STUDY FRAUD AND ABUSE 2021 - Saved to my Mac Layout References Mailings Review View Tell me LE Shar " A" A Aa Ap AaBbCcDdEe AaBbCcDdEe Normal Styles Dictat X X A D A v No Spacing Pane This Case Study Relates to Chapter 16 Fraud and Abuse and 7 PERFORMANCE IMPROVEMENT Fraud, abuse and waste in Medicaid cost states billions of dollars every year, diverting funds that could otherwise be used for legitimate health care services. Not only do fraudulent and abusive practices increase the cost of Medicaid without adding value - they increase risk and potential harm to patients who are exposed to unnecessary procedures. In 2015, improper payments alone-which include things like payment for non-covered services or for services that were billed but not provided-totaled more than $29 billion according to the Government Accountability Office. While Medicaid fraud involves knowingly misrepresenting the truth to obtain unauthorized benefit, abuse includes any practice that is inconsistent with acceptable fiscal, business or medical practices that unnecessarily increase costs. Waste encompasses overutilization of resources and inaccurate payments for services, such as unintentional duplicate payments. As states look for innovative ways to contain burgeoning Medicaid costs and promote the program's integrity, fighting fraud and abuse offers one approach that everyone can support. The Vice President of Compliance in a 440 bed inner city hospital received a message on the Compliance Hot Line that a Billing Clerk was upcoding the admitting diagnosis of all patients admitted through the emergency room. An example was a 38 year old female Medicaid patient originally diagnosed with a mild gastrointestinal problem was upcoded to colitis eligible for a reimbursement of $400 vs. a triage reimbursement of $150. Upon investigation, it was found that the Billing Clerk was upcoding. ASSIGNMENT: In a two page single spaced jyped paper 1. Identify the issue; 2. Referring to the textbook how English (United States) Focus E 3 DOCS R US MINI CASE STUDY At MacBook Air DII DD E6 F7 F8 F9 F10 F11 6 O - 8 9 Y U O P G H C K 

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- Part1l The problem is that the Billing Clerk is increasing the Medicaid reimbursement by upsetting patient diagnoses. To boost Medicaid reimbursement, the Billing Clerk was upcoding the diagnosis of indwlduals admitted through the EB. As a result, the hospital could be audited and investigated by Medicaid as a result oi this problem. It's possible that patients could be put in danger if they're given a diagnosis that they don't have. Patients, the Vice President of Compliance, and the Billing Clerk are all stakeholders in this issue. u Part 2 False information provided by the Billing Clerk about the severity of the patients' ailments could be considered fraud or abuse. All patients admitted through the emergency room had their diagnoses fraudulently upcoded by the billing clerk. Thus, the hospital was compensated more than they were entitled to for the patients they treateIi as a result oi this. . Partfi These laws, as well as Stark and the AntirKickback Statute, could be broken by the billing clerk's actions. According to the Anti—Kickback Statute and the Fate Claims Act, a Billing Clerk was found 5. The False Claims Act makes it illegal to submit claims to the government ion of the Anti-Kickback Statute would be a violation guilty oi tiling false invoice for payment that are ialse or fraudulent. A violat oi federal health care programs' prohibition o n kickbacks. 

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Fm"— .. .. . ...._ ......._ - Part 4 it's imperative that the VP conducts an investigation into the disputed claims to see if they were in fact. upcoded. This billing clerk should be disciplined by the VP if this is the case. Depending on gravity of i. the act, this could involve a warning, suspension, or even dismissal trom the company Additionally; the; h _ l. ._ VP should implement measures to avoid this from happening again. Billing clerks could receive f}? F greater instruction in coding processes, and claims could be audited more frequently as a result. _l 5-. - Part 5 f ' Z; [I -. I l in addition to a problem with compliance. this may be considered a problem with quality as well. incorrect placement of patients in higher levels of care (and higher reimbursement} due to upcoding can occur. When a patient isn't appropriately supervised or receives therapies that they don't genuinely require. this could result in harm to the patient. As a result of upcoding. the hospital's costs may rise. Overbilling may result in financial consequences for the hospital if it receives .: reimbursements that are larger than they should be. Finally. upcoo'ing might tarnish the reputation eta" ' hospital with the public. Patients and sEtalf may have a hard time attracting to the hospital if file ' revealed that it has been upcodlng. Step-by-step explanation . _ . All regulations must be adhered to by the vice President of W mm hospital to be considered compliant. In the emergency room. m .._. .i: ........ ._ ._ Int-r ins 

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Question Answer B. Explanation Related Questions Related Courses __.....M . Part1- ---. - -................m_¥____-_F__ . All regulations must be adhered to by the Vice President of Compliance in order for the hospital to be considered compliant. In the emergency room, patients' diagnoses must be coded by the Billing Clerk. inaccurate diagnoses are being given to patients. immediately, the Vice President of Compliance should take action. Billing Clerk shoutd be questioned about . When confronted with the circumstance. the what they were thinking and doing. Immediately fire the Billing Clerk if they are found to be willtuiiy upcoding diagnoses. In order to prevent this from happening again, the hospital's Vice President of Compliance should examine the hospital's billing procedures. . The Billing Clerk enters diagnoses into the hospital's billing system after they have been coded. immediately fire the Billing Clerk if they are found to be willfully upcoding diagnoses. in order for the hospital to receive more money from insurance companies. upcoding is an illegal practice. If this happens again. the hospital's Vice President of Compliance should conduct an audit of the hospital's billing procedures. ensuring that the hospital is in compliance with all applicable rules and regulations. An key aspect of ensuring compliance is to review the billing practices. it's imperative that the hospital's Vice President of Compliance take action if they discover that the hospital's billing practices aren't in line with legal requirements. l I . Changing. the way diagnoses are coded or the way the hospital fees for services could I be a part ct this. To make sure that the hospital's billing methods are in accordance with g the Vice President of Compliance is in charge. The - he i the Vice President of Compliance does not - He or she is responsible for the applicable rules and regulations. hospital coutd be fined or lose its Iicensei take action to fix the problem. 

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Question Answer & Explanation Related Questions Related Courses - The Accounting Intern was upcoding client diagnosis and submitted them to the federal govt for payment in a dishonest or erroneous manner. Anti—Kickback Statute violations occurred as a result of receiving bribes for recommending patients to federally-funded programs. Both of these offences are punishable by tines andlor prison term. - in order to get money from the United States government. it is illegal to make false or fraudulent claims. If you intentionally ask, encourage. aid. Counsel. or advise another individual to file s [also or fraudulent claim with the government one is committing a crime as well. . False statements or representations of material facts are banned by federal law in any document or application for payment to the government. Submission of a complete and accurate applic ation, claim, form or document is required by anybody applying fer payment. whether directly or indirectly {whether paper or electronic). - On a Government contract. lying about your professional licenses. education. and career history may also be a violation of federal criminal law. Anti-kickback legislation also makes it illegal to pay bribes 'to induce the referrat of medicalty necessary products or services that are covered by federal heallh care programs. - To avoid violating the Anti—Kickback Statute. hospitals can't give money away to get .,_ H people to recommend products or services {or which FMS will pay. Certain financial ties Q at between doctors and hospitals that take part in the Medicare and Medicaid programs are _ prohibited by the Stark Law. $223: . Patients" access to care may be jeopardized i! a doctor's independence and discretion Low m, are compromised by tinancial lies to companies that benefit lrom the services the doctor provides. 

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Question Answer & Explanation Related Questions Related Courses . Part 4 . The VP should address the Clerk's coding errors right away and look into the situation further to see if there is any fraudulent intent.. To prevent future instances of upcoding, the VP should consider putting in place controls. Hospital billing and coding procedures should be improved in the long run to ensure that all claims are correct and compliant at Let all times. 24/ . Making improvements to the software utilized, employing more people, or boosting training and education for all employees involved in the billing and coding process could all be part of the solution.. He or she can begin by disciplining the employee at issue. . This should be dealt with swiftly and aggressively if there have been previous incidences of upcoding, as a single mistake can lead to a slippery slope of upcoding. In addition, the VP should put in place processes to prevent upcoding. Among the options here are more frequent audits by accounting to make sure the correct code is being used for each claim and better training for billing clerks on coding practices. . A variety of fraudulent behaviors can be uncovered when billing clerks are involved in upcoding. A warning or a memo may sufficient if the individual was simply being careless and "mistakenly" upcoded an item. Disciplinary action may be required if the individual Ha was intentionally trying to trick the company into paying more than they should. . Depending on the gravity of the problem, the response could range from a warning to Enrich yo dismissal. Additionally, the vice president should make it clear that any additional explanati attempts to upcode will result in harsher consequences including pay reductions and Learn more perhaps firing. The VP should also take steps to prevent future instances, such as strengthening training for billing clerks and instituting more rigorous auditing 13 A 

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Question Answer & Explanation Related Questions Related Courses . The VP can't allow the billing clerks to keep submitting incorrect claims. It is imperative that the circumstances surrounding this incident be thoroughly investigated in order to avoid a recurrence. Additional training for all billing clerks on coding processes and more At Ask frequent audits of the claims submitted should be put in place by the VP to avoid this from happening again. Let our expert 24/7. Answers . Part 5. Patients may not receive adequate care as a result of upcoding, which is both a Enter a ques compliance and a quality concern. Billing for a more expensive service or product than what was actually given is known as "upcoding. It's not uncommon for a hospital to upcode a patient's diagnosis from a cold to pneumonia in order to get a larger insurance payout. P 3b . As a result of improperly assigning patients to greater levels of care than they actually require, upcoding can be viewed as a problem of quality. When a patient isn't Ask a appropriately supervised or receives therapies that they don't genuinely require, this could result in harm to the patient. Due to this, patients may be placed in a higher degree of treatment than they actually need, which may result in a greater payment. . When a patient isn't appropriately supervised or receives therapies that they don't Have a docume genuinely require, this could result in harm to the patient. It is possible for a hospital to studying? overcharge Medicare in one of two ways: An example of upcoding by the hospital, patient Enrich your document should have been charged for services at a lower level, which is an error. explanations, and related It's possible that an expensive diagnosis code that was never utilized by the medical Learn more about this facility may be claimed for. Another possibility is that the hospital isn't actually "upcoding," but rather providing more expensive services than are actually required. Upload your 13 Q esc F3 
 
 
 
 
 
 
 

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Vindow Help uny.edu/webapps/blackboard/content/listContent.jsp?course_id=_2236889_1&content_id=_71913 CASE STUDY FRAUD AND ABUSE 2021-Saved to my Mac Tell me Layout References Mailings Review View EE n 0 X X ' ' 9 F4 V Aa v AA English (United States) 3 DOCS R US MINI CASE STUDY A % 5 T G F5 B tv A 6 Y F6 FO H MacBook Air This Case Study Relates to Chapter 16 Fraud and Abuse and 7 PERFORMANCE IMPROVEMENT M Fraud, abuse and waste in Medicaid cost states billions of dollars every year, diverting funds that could otherwise be used for legitimate health care services. Not only do fraudulent and abusive practices increase the cost of Medicaid without adding value - they increase risk and potential harm to patients who are exposed to unnecessary procedures. In 2015, improper payments alone which include things like payment for non-covered services or for services that were billed but not provided-totaled more than $29 billion according to the Government Accountability Office. While Medicaid fraud involves knowingly misrepresenting the truth to obtain unauthorized benefit, abuse includes any practice that is inconsistent with acceptable fiscal, business or medical practices that unnecessarily increase costs. Waste encompasses overutilization of resources and inaccurate payments for services, such as unintentional duplicate payments. As states look for innovative ways to contain burgeoning Medicaid costs and promote the program's integrity, fighting fraud and abuse offers one approach that everyone can support. The Vice President of Compliance in a 440 bed inner city hospital received a message on the Compliance Hot Line that a Billing Clerk was upcoding the admitting diagnosis of all patients admitted through the emergency room. An example was a 38 year old female Medicaid patient originally diagnosed with a mild gastrointestinal problem was upcoded to colitis eligible for a reimbursement of $400 vs. a triage reimbursement of $150. Upon investigation, it was found that the Billing Clerk was upcoding. & 7 U ASSIGNMENT: In a two page single spacedyped paper 1. Identify the issue; 2. Referring to the textbook how Focus G F7 J * 0 2 8 A DII F8 I AaBbCcDdEe K ( 9 Normal F9 O AaBbCcDdEe No Spacing L ) 0 A F10 P > E Styles Pane 4 F11 LE { [ + 11 Share Dictate Vindow Help uny.edu/webapps/blackboard/content/listContent.jsp?course_id=_2236889_1&content_id=_71913 CASE STUDY FRAUD AND ABUSE 2021-Saved to my Mac Tell me Layout References Mailings Review View EE n 0 X X ' ' 9 F4 V Aa v AA English (United States) 3 DOCS R US MINI CASE STUDY A % 5 T G F5 B tv A 6 Y F6 FO H MacBook Air This Case Study Relates to Chapter 16 Fraud and Abuse and 7 PERFORMANCE IMPROVEMENT M Fraud, abuse and waste in Medicaid cost states billions of dollars every year, diverting funds that could otherwise be used for legitimate health care services. Not only do fraudulent and abusive practices increase the cost of Medicaid without adding value - they increase risk and potential harm to patients who are exposed to unnecessary procedures. In 2015, improper payments alone which include things like payment for non-covered services or for services that were billed but not provided-totaled more than $29 billion according to the Government Accountability Office. While Medicaid fraud involves knowingly misrepresenting the truth to obtain unauthorized benefit, abuse includes any practice that is inconsistent with acceptable fiscal, business or medical practices that unnecessarily increase costs. Waste encompasses overutilization of resources and inaccurate payments for services, such as unintentional duplicate payments. As states look for innovative ways to contain burgeoning Medicaid costs and promote the program's integrity, fighting fraud and abuse offers one approach that everyone can support. The Vice President of Compliance in a 440 bed inner city hospital received a message on the Compliance Hot Line that a Billing Clerk was upcoding the admitting diagnosis of all patients admitted through the emergency room. An example was a 38 year old female Medicaid patient originally diagnosed with a mild gastrointestinal problem was upcoded to colitis eligible for a reimbursement of $400 vs. a triage reimbursement of $150. Upon investigation, it was found that the Billing Clerk was upcoding. & 7 U ASSIGNMENT: In a two page single spacedyped paper 1. Identify the issue; 2. Referring to the textbook how Focus G F7 J * 0 2 8 A DII F8 I AaBbCcDdEe K ( 9 Normal F9 O AaBbCcDdEe No Spacing L ) 0 A F10 P > E Styles Pane 4 F11 LE { [ + 11 Share Dictate

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