Case Study Medicare Fraud and Abuse Report ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Case Study Medicare Fraud and Abuse Report In this assignment we examine the legal and ethical implications of fraud and abuse with Medicare. Use the CSU-Global Library and the internet to identify a real-world case of Medicare fraud and/or abuse. Write a 4-5 page report using the readings, research, and your knowledge of health law and ethics to analyze this case. Case Study Medicare Fraud and Abuse Report Your report should address the following substantive requirements: ·Description of what occurred, who was affected, and why ·Assess the case from the following perspectives: ·Ethical identify the ethical principles involved in this situation from the perspective of all those involved. ·Legal what are the legal implications and what laws or statutes were involved? ·Provide two recommendations for how to manage this case from the perspective of the healthcare organization involved. What could have been done to prevent this situation? ·Recommend next steps to manage this case. Your report should meet the following structural requirements: ·Be 4-5 pages in length, not including the cover or reference pages. ·Be formatted according to APA formatting and requirements ·Provide support for your statements with in-text citations from a minimum of four (4) scholarly articles. Two (2) of these sources may be from the class readings, textbook, or lectures, but two (2) must be external. ·Utilize the following headings to organize the content in your work. Case Study Medicare Fraud and Abuse Report ·Introduction ·Assessment ·Recommendations ·Conclusion hcm515___ct___grading_rubric.pdf contemporary_issues_in_healthcare_law_and_ethics___4th_edition__ch.8.pdf medicare_and_medicaid_fraud_and_compliance_plans.pdf medicare_part_d_and_lon HCM515 Critical Thinking Rubric Module 5 Meets Expectation Content, Research, and Analysis 13-15 Points Requirements Includes all of the required components, as specified in the assignment, including length, construction of a report or presentation based on the assigned case study that accounts for the four substantive and four structural requirements provided. 17-20 Points Content Demonstrates strong or adequate knowledge of the materials with respect to health law, ethics, and Medicare fraud/abuse; correctly represents knowledge from the readings and sources. 17-20 Points Critical Analysis Provides a strong critical analysis and interpretation based on the information given; shows strong critical thinking in addressing legal and ethical implications of the Medicare fraud. Approaches Expectation Below Expectation Limited Evidence 10-12 Points Includes most of the required components, as specified in the assignment. 7-9 Points Includes some of the required components, as specified in the assignment. 4-6 Points Includes few of the required components, as specified in the assignment. 13-16 Points Some significant but not major errors or omissions in demonstration of knowledge. 9-12 Points Major errors or omissions in demonstration of knowledge. 5-8 Points Fails to demonstrate knowledge of the materials. 13-16 Points Some significant but not major errors or omissions in critical analysis. 9-12 Points Major errors or omissions in critical analysis. 5-8 Points Fails to provide critical analysis and interpretation of the information given. HCM515 Critical Thinking Rubric Module 5 13-15 Points Problem Solving Demonstrates strong or adequate problem solving skills, applied thought and insight in addressing specific problems in the recommendation section of the assignment. 9-10 Points Sources Cites and integrates at least 4 credible sources as specified in description. 9-10 Points Application of Sources well or Source Material adequately chosen to provide substance and perspectives on the issue; knowledge from the course linked properly to source material. Mechanics and Writing 9-10 Points Demonstrates Project is clearly college-level organized, well proficiency in written, and in organization, proper format as grammar and outlined in the style. assignment. Strong sentence and paragraph structure; few errors in grammar and spelling. 10-12 Points Some significant but not major errors or omissions in problem solving and applied thinking. 7-9 Points Major errors or omissions in problem solving and applied thinking. 4-6 Points Fails to demonstrate problem solving and applied thinking. 7-8 Points Cites and integrates 3 credible sources as specified in description. 7-8 Points Some significant but not major problems with selection and linkage of sources. 5-6 Points Cites and integrates 1 or 2 credible source as specified in description. 5-6 Points Major problems with selection and linkage of sources. 3-4 Points Cites and integrates no credible sources. 7-8 Points Project is fairly well organized and written, and is in proper format as outlined in the assignment. Reasonably good sentence and paragraph structure; significant number of errors in grammar and spelling. 5-6 Points Project is poorly organized; does not follow proper paper format. Inconsistent to inadequate sentence and paragraph development; numerous errors in grammar and spelling. 3-4 Points Project is not organized or well written, and is not in proper paper format. Poor quality work; unacceptable in terms of grammar and spelling. 3-4 Points Source selection is seriously flawed; no linkage to knowledge from the course. HCM515 Critical Thinking Rubric Module 5 Demonstrates proper use of APA style 9-10 Points Project contains proper APA formatting Total points possible = 110 7-8 Points Few errors in APA formatting 5-6 Points Significant errors in APA formatting 3-4 Points Numerous errors in APA formatting PRINTED BY: Matthew Langner . Case Study Medicare Fraud and Abuse Report Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission.Case Study Medicare Fraud and Abuse Report Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publishers prior permission. Violators will be prosecuted. Call (407) 331-6620 (850) 439-1001 Contact Us Online Search Our Website Go Medicare and Medicaid Fraud and Compliance Plans MEDICARE AND MEDICAID FRAUD AND COMPLIANCE PLANS by George F. Indest III, J.D., M.P.A., LL.M. SCOPE OF ARTICLE In this article, the author reviews the basics of Medicare and Medicaid fraud initiatives generated by the Office of the Inspector General and the State. This article reviews the State and Federal laws that are used to prosecute or obtain civil recovery from physicians in Medicare and Medicaid cases. Case Study Medicare Fraud and Abuse Report The article also covers the guidance recently issued by the Office of the Inspector General for compliance plans for small medical practices. Sufficient information is provided for a physician or small medical group to design a Medicare & Medicaid compliance program. §1 Compliance and Fraud and Abuse: Introduction There is probably no other area of such significant legal importance to a physician who treats Medicare and Medicaid patients as the area of fraud and abuse and compliance. §2 The OIG Sees a Problem with Fraud and Abuse in the Medicare Program According to the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS), the Federal agency responsible for the overall supervision of health care programs in the United States, including the Medicare and the Medicaid Programs, improper fee-for-service Medicare payments decreased by 12 percent overall from 1999 to 2000, but improper payments to physicians increased by 22 percent.1 These improper physician payments break down as follows: 2000 1999 Documentation missing or incomplete: $1.0 Billion $1.1 Billion Medically unnecessary: $0.6 Billion $0.1 Billion Coding errors: $1.7 Billion $1.5 Billion TOTAL: $3.3 Billion $2.7 Billion §3 The OIG Sees a Solution to Fraud and Abuse in the Medicare Program According to OIG, the Federal governments efforts in controlling fraud and abuse in Federal health care programs continue to bear fruit. From fiscal year 1997 until September 2001, the OIG reported overall savings of more than $65.31 billion. This is comprised of $1.07 billion in audit disallowance, $59.4 billion in savings from implemented legislative or regulatory recommendations and actions to put funds to better use, and $4.9 billion in investigative receivables. Medicare and Medicaid accounted for more than 98 percent of the total savings, with the balance attributable to various other HHS programs. In FY 2000 alone, Medicare and Medicaid accounted for more than $15.42 billion of the record $15.62 billion in overall savings. The OIG reports significant enforcement achievements during the span of FY 97 to September 2001, 2 including: The exclusion of more than 15,822 abusive or fraudulent individuals and entities from doing business with Medicare, Medicaid, and other Federal and State health care programs. 1,714 successful criminal prosecutions. 3,497 civil actions against individuals or entities engaged in fraudulent conduct against departmental programs. As provided for in the Federal law known as the Health Insurance Portability and Accountability Act (HIPAA),3 most of the money recovered in the form of judgments, settlements and administrative penalty impositions from these cases has been or will be returned to the Medicare Trust Fund. §4 The Medicaid Program and Medicaid Fraud There are somewhat similar problems and somewhat similar concerns with the Medicaid Program and other state and federal programs, as well. [1] The Medicaid Program Medicaid is a joint Federal and State-funded program. The Federal government mandates certain eligibility classes and quality of care standards, with the bulk of the administrative functions being carried out by the States. However, enforcement is left primarily to the State with the Federal government providing overall supervision and guidance. In the Federal government, the Medicaid Bureau has been part of the Health Care Financing Administration (HCFA),4 a division of the Department of Health and Human Services (HHS). However, in 2000, the agency was renamed the Centers for Medicare & Medicaid Services (CMS) and refocused along its three primary lines of service the Center for Medicare Management, Center for Beneficiary Choices and the Center for Medicaid and State Operations. These three (3) centers are designed to clearly reflect the agencys major lines of business: traditional fee-for-service Medicare; Medicare+Choice and state-administered programs, such as Medicaid and SCHIP. Case Study Medicare Fraud and Abuse Report The Center for Medicare Management will focus on management of the traditional fee-for-service Medicare program. This includes development of payment policy and management of the Medicare fee-for-service contractors. The Center for Beneficiary Choices will focus on providing beneficiaries with information on Medicare, Medicare Select, Medicare+Choice and Medigap options. It also includes management of the Medicare+Choice plans, consumer research and demonstrations, and grievance and appeals functions. The Center for Medicaid and State Operations will focus on programs administered by states. This includes Medicaid, the State Childrens Health Insurance Program (SCHIP), insurance regulation functions, survey and certification, and the Clinical Laboratory Improvements Act (CLIA). The State agency responsible for administering the States Medicaid Program, including performing audits on Medicaid providers is usually referred to as the Medicaid Agency. In Florida the Medicaid Agency is the Agency for Health Care Administration (AHCA). [2] Overview of Medicaid Fraud in the United States With annual health care costs in the U.S. now exceeding $1 trillion, fraud and abuse in the Medicaid Program is costing taxpayers billions of dollars each year, according to the Federal Medicaid Bureau. The Medicaid Programs price tag has risen from $3.9 billion in 1968 to more than $130 billion in 1993. The programs cost has risen so significantly for a variety of reasons, but HCFA, and now CMS, decided to focus on the tremendous amount of money lost to fraud and abuse.5 CMS effort to detect and prevent fraud and abuse in the Medicaid program is based on a partnership and cooperative effort with beneficiaries, Medicaid providers, contractors, and state and federal agencies such as state Medicaid Fraud Control Units, state Surveillance and Utilization Review Units (SURU), the Office of the Inspector General (OIG), the Federal Bureau of Investigation (FBI), the Department of Justice (DOJ) and Congress. While the states are primarily responsible for policing fraud in the Medicaid program, CMS provides increased technical assistance and guidance to these efforts. Fraud schemes often cross program lines and CMS continues to improve information sharing between Medicare and the nations 57 State Medicare programs. For example, the South Florida Task Force demonstration had Medicare contractors, Medicaid state agencies, U.S. Attorneys and Medicaid Fraud Control Units working together for the first time detecting fra
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