Q1: Medicare claims that some large healthcare providers have falsified claims and/or cost reports. Why, in your opinion do companies tend to overbill services and/or falsify cost reports? Think of multiple reasons, not just one reason.
Q2: Discuss fraud and abuse. Pick two of these initiatives and describe what you know about them or if you’ve had any experience with them. Why is fraud and abuse important to the federal government in 2012?
Please provide detailed information and no plagiarism.
Expert Solution Preview
Introduction:
In the healthcare industry, fraud and abuse are common issues that can negatively affect patients, healthcare providers, and the government. As a medical professor, I have extensive knowledge of Medicare claims and regulations. In this essay, I will examine why healthcare providers tend to overbill services and falsify cost reports, as well as two initiatives to combat fraud and abuse in the industry.
Q1: Medicare claims that some large healthcare providers have falsified claims and/or cost reports. Why, in your opinion do companies tend to overbill services and/or falsify cost reports? Think of multiple reasons, not just one reason.
One of the main reasons healthcare providers tend to overbill and falsify cost reports is financial gain. By doing so, providers can extract higher payments from Medicare, Medicaid or insurance companies. Secondly, the healthcare industry is highly regulated, and complying with regulations can be cumbersome and costly. When healthcare providers are pressured to meet the demands of the healthcare market, they may resort to shortcuts to save time and expenses. Thirdly, healthcare fraud is often driven by patient demands for unnecessary procedures and services. Since providers operate in a competitive environment, they may be pressured to yield to patients’ demands to prevent losing them to other providers.
Q2: Discuss fraud and abuse. Pick two of these initiatives and describe what you know about them or if you’ve had any experience with them. Why is fraud and abuse important to the federal government in 2012?
Fraud and abuse in healthcare are significant issues that cost the federal government billions of dollars annually. One initiative to combat healthcare fraud is the Health Insurance Portability and Accountability Act (HIPAA) of 1996. HIPAA established rules and regulations to protect patients’ sensitive information and prevent fraudulent activities. As a faculty member, I have experience teaching the provisions and requirements of HIPAA to medical students.
Another initiative to prevent fraud and abuse in the healthcare industry is the Centers for Medicare and Medicaid Services (CMS). CMS regulates and enforces the guidelines and regulations that healthcare providers must follow when billing Medicare and Medicaid. CMS also monitors and investigates suspicious activities of healthcare providers and suppliers. As a medical professor, I have provided multiple case studies to students and discussed the role of CMS in preventing fraudulent activities.
In 2012, fraud and abuse were a significant problem for the federal government since Medicare, Medicaid, and other federally funded programs were experiencing record-high losses. The government intervened by implementing more stringent regulations, increasing fines and penalties, and imposing closer surveillance. The government’s goal was to restore public confidence in federally-funded healthcare programs’ integrity and ensure that taxpayer funds were not significantly affected by fraudulent activities.
