Reference no: EM133845365

CASE STUDY : FRAUD AND ABUSE IN HEALTHCARE

You are the manager of a large multispecialty medical practice. About 10 years ago, before you were employed by the practice, CMS randomly audited the records of 25% of your Medicare claims and found some discrepancies. The practice had to reimburse CMS $50,000 in Medicare fees due to undocumented services, lack of medical necessity and issues with upcoding. Since then, the providers insist that the manager conduct regular training sessions with employees to ensure all medical records are properly documented, legitimately justifying medical necessity for any services provided by the diagnosis for each patient. You are in the process of updating the information that will be covered for employees at the mandatory training session.

QUESTIONS

1. Define healthcare fraud and abuse and distinguish between them.

2. Describe three examples of healthcare fraud.

3. Identify three types of billing abuse.

4. Explain best practices to maintain compliance with all regulatory standards.

5. Summarize three laws used to prosecute healthcare fraud.

6. Relate the legal concept of respondeat superior to employer responsibility for healthcare fraud and abuse.

7. Discuss the role of the Office of Inspector General, OIG, to healthcare fraud.