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Health care fraud and abuse are punishable by US law. Providers are fined, can be excluded from Medicare, and staff will face civil or criminal penalties (Harrington, 2019). There are Stark Law, the False Claim Act, and the Anti-Kickback Statute. The Centers for Program Integrity monitors and enforces these laws and implements legal and regulatory tools. Legal prevention methods are effective because the presence of criminal liability for fraud or abuse forces employees to approach work with dignity (Harrington, 2019). The Health Insurance Portability and Accountability Act (HIPAA) allows for regulating both legal and ethical violations. HIPAA establishes whether an action is abusive or rational, and fines are imposed depending on that (Harrington, 2019). The severe consequence for the provider is exclusion from Medicare or Medicaid. It limits an organizations allowable budget and makes it challenging to follow up with medical care. It controls costs and obligates the provider to manage staff actions.
Ethical anti-fraud and abuse practices include monitoring medication and treatment prescribing, payments and compliance, and patient and staff card generation. Recovery audit contractors allow practices and services to determine compliance with their price and avoid financial fraud by the organization (Terra, 2009). In addition, in this way, it is possible to achieve complete consistency between appointments and payments. Pay-for-performance is an effective tool to counteract fraud because this system limits how, to whom, and how many procedures are performed (Catalano, 2009). Among ethical practices, Harrington also points to the need for cooperation in risk areas where there is a fine line between the norm and abuse for example, intensive care (Harrington, 2019). Ethical practices will be effective if they are closely tied to the finances and internal policies of the provider.
Fraud and abuse cause significant financial losses to the organization: for example, exclusion from Medicare or Medicaid results in the loss of payers and patients. Criminal and civil penalties for regulatory violations result in fines of as high as $4 million (Harrington, 2019). As a result, providers do not have funds for the organizations other needs. Implementing service delivery standards and checking for pricing and ethical policies will prevent fraud and abuse. Reporting (financial, logistical, and legal) will establish the existence of systemic violations. Auditing and monitoring will establish whether personnel are responsible for their actions and whether all essential services are included in the reporting.
References
Catalano, K. (2009). Pay-for-performance and recovery audit contractors: The whys and wherefores of these programs.Plastic Surgical Nursing: Official Journal Of The American Society Of Plastic And Reconstructive Surgical Nurses, 29(3), 179182.
Harrington, M. K. (2019). Healthcare fraud and abuse. In Health Care Finance and the Mechanics of Insurance and Reimbursement (2nd ed.) (pp. 189-202). Jones & Bartlett Learning.
Terra, S. M. (2009). Regulatory issues: Recovery audit contractors and their impact on case management. Professional Case Management, 14(5), 217-223.
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