Healthcare

Abusing Medicare and Medicaid privileges is a serious issue: it will cost the country billions of taxpayers' money and compromise the wellbeing of our beneficiaries. This course will give you an overview of what is expected of us as trustworthy medical practitioners so we can maintain and nurture our clients' trust; discuss what is medicare fraud and abuse; and teach you how to detect, prevent, and report these medicare issues.

Welcome!
Aside from providing good healthcare services, we value our customers’ trust when it comes to us fulfilling their needs.
This course emphasizes the importance of being a proper and trustworthy healthcare provider.


Overview
In this lesson, you will learn...
What is expected of a trustworthy healthcare provider,
A short overview of what is medicare fraud and abuse,
What relationships we need to foster and nurture that may go awry with these medicare issues, and
The existing laws for medicare fraud and abuse.


At the core of every physician-patient relationship is trust.
We are expected to provide medical work that is...
...ethical, high quality, and properly-documented.
Our clients and the Federal healthcare programs trust in our:
medical judgment in treating our patients appropriately,
providing all necessary services the patients require, and
being transparent and accurate with our Medicare-covered claims.
To gain our clients' and customers' trust, we'll introduce you to the concepts of medicare abuse & fraud.
This is imperative in nurturing our pre-existing relationships with our clients, customers, and other institutions.


What is expected of a trustworthy healthcare provider?


Overview

Medicare  Fraud vs. Abuse
What's the difference?


Welcome back!
Last lesson, we gave you an overview of what is expected of us as trustworthy medical practitioners.
In this lesson, we will delve more into what constitutes medicare abuse & medicare fraud.


Overview
In this lesson, we will...
Show you the spectrum of "Improper Payments" that you may find yourself in,
Distinguish what medicare abuse is from medicare fraud, and
Challenge you with simulations to help you identify which of the two offenses are being committed.


The sample figure was only an example for educational purposes of how these errors in payments may impair our program's integrity.
Each improper payment must undertake a full analysis based on its specific context --
which is to say not all who has done:
incorrect coding,
excessive orders,
inaccurate billing codes, or
excessive billing
...will be punished under administrative, civil, or criminal liability.


Improper payments can take different forms.


Financial Costs
An aspect of medicare abuse is concerned with Medicare programs expending large amounts of unnecessary expenses.
The cause of the harm may be direct or indirect. The focus is on the** financial consequences**.


The Patient's Welfare
Another form of medicare abuse is depriving our patients or clients of proper, professional, or standard services, regardless of sex, age, gender, class, or race.
This kind of abuse takes for granted the medical needs of our patients.


Medicare abuse compromises the program's integrity.
It also makes medical institutions susceptible to criminal or civil liability.
To combat medicare abuse, we must work on pinpointing the causes of our institution's improper payments.


Which of the following is considered medicare abuse?


Culpability
With medicare fraud, there is no room for accidents-- they presuppose that the act was done knowingly and willfully, regardless of the consequences.


What does Medicare Fraud look like?
So in understanding medicare fraud, the perpetrators are assumed to knowingly and willingly...
Declare false claims,
**Bribe **someone, or
Making representations without credibility.


Referring patients to medical institutions that you have a vested financial interest in* and
Seek, receive, or offer payment from kickbacks, briberies, and rebates.
*This is in accordance with the Stark Law.


Fraudsters do this to **reimburse **Federal healthcare programs through intentional deception.
Medicare Fraud is harmful to multiple entities and is liable to criminal, civil, and administrative punishment.
These fraudulent schemes may even result to penalties, fines, or imprisonment.


What's the Difference?

Medicare  Fraud & Abuse
Detection, Prevention, & Reporting


Welcome back!
In the past lessons, you've been acquainted with the spectrum of improper payments and what constitutes medicare fraud and abuse.
In this last lesson, we will focus on helping you spot the signs and give you an action plan whenever you're confronted with one.


Overview
In this lesson, we will...
Teach you how and where to spot the signs of Medicare fraud and abuse,
Give you an overview of the compliance programs for our medical institution,
List the existing partnerships and agencies committed to combat Medicare anti-fraud & abuse, and
Give you a protocol for reporting suspected fraud.


Healthcare constituents, most especially physicians, must establish compliance programs to help avoid abuse and fraud.
The strength of the compliance program can be assessed through the following components:
Does the program regularly conduct internal monitoring and auditing?
Does the implemented program have **standards **for compliance and practice?
Does the program have a compliance officer or head?
Does the program administer quality training and education?
Does the program have a proper protocol for accountability and corrective action for committed offenses?
Does the program uphold a culture of open communication and honesty?
Does the program have disciplinary standards and well-publicized guidelines for the constituents?


What are our  medicare-related compliance programs?


If you suspect that you might be engaging with potentially fraudulent or abusive billing practices, you may:
Refrain from transacting with the suspicious bills unless you've clarified your worries.
Contact your lawyer or seek legal counsel.
Do some accounting:
Which bills may have been erroneously collected from Medicare?
When you have your answers, **report **the incidents and return the overpayments.
4. ## Take action with the problematic investment by refusing to engage or getting involved unless the matter is resolved.
5. ## Cut your relationship with the suspicious entity.
6. ## Review OIG and CMS's self-disclosure protocols and assess how they may help you.


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Medicare Fraud and Abuse

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