You are a corporate compliance officer for a hospital. You are also a feature writer for
The Medical Reporter
, an online health magazine. The editor asks you to write an 8-10 page feature story about the steps you should take when fraud and abuse cases are reported to a facility. This is very timely as you recently received a call on your “hotline” regarding a potential fraud and abuse issue. The caller indicated that Dr. Greedy was billing for services that had not been provided. You are in danger of losing reimbursement for Medicare and Medicaid programs if this behavior is not stopped. Your feature should address the ethical and moral components that healthcare providers and healthcare facilities face with fraud and abuse issues. Your research should include the following aspects:
How to conduct an investigation. It should include the following elements:
Reviewing the initial complaint: What are the items you should look for in a compliant to determine validity?
Notifying the appropriate upper management of the complaint unless they are implicated in the complaint: What are the steps to take to determine who is involved?
Obtaining additional information as necessary and developing a plan for the investigation: What other items are important to the investigation?
Conducting interviews with staff, residents and/or management: Delineate the types of questions to ask in the interview.
Determining if the allegations are substantiated or unsubstantiated: Identify criteria to determine if substantiated or unsubstantiated.
How to develop a correction action plan. The plan may suggest:
A recommendation for a subsequent audit or follow-up to the complaint and determination of when this is necessary.
A recommendation to refund any overpayments to federal government, insurance company or individual payer and when that may be the best course of action.
By
the due date assigned
, deliver your assignment to the
Submissions Area.
Use the following file naming convention: LastnameFirstInitial_M5_A1.doc.
Assignment 1 Grading CriteriaMaximum Points
Discussed the process for reviewing the initial healthcare fraud and abuse complaint and the items to look for to determine validity.
-Explained the steps to take to determine who is involved in the complaint.32Discussed how to obtain additional information to develop a plan for the investigation and the items, which would be important to the investigation.-
-Explained how to conduct interviews with staff, residents and/or management and the types of questions to ask in the interview.-
-32Identified the criteria to determine if the allegations are substantiated or unsubstantiated.32Explained how to determine when a recommendation for a subsequent audit or follow-up to the complaint is necessary.
-Discussed the best course of action when a recommendation to refund any overpayments to federal government, insurance company or individual payer is warranted.
-Written Compon ...
You are a corporate compliance officer for a hospital. You are also
1. You are a corporate compliance officer for a hospital. You are
also a feature writer for
The Medical Reporter
, an online health magazine. The editor asks you to write an 8-
10 page feature story about the steps you should take when
fraud and abuse cases are reported to a facility. This is very
timely as you recently received a call on your “hotline”
regarding a potential fraud and abuse issue. The caller
indicated that Dr. Greedy was billing for services that had not
been provided. You are in danger of losing reimbursement for
Medicare and Medicaid programs if this behavior is not
stopped. Your feature should address the ethical and moral
components that healthcare providers and healthcare facilities
face with fraud and abuse issues. Your research should include
the following aspects:
How to conduct an investigation. It should include the
following elements:
Reviewing the initial complaint: What are the items you should
look for in a compliant to determine validity?
Notifying the appropriate upper management of the complaint
unless they are implicated in the complaint: What are the steps
to take to determine who is involved?
Obtaining additional information as necessary and developing a
plan for the investigation: What other items are important to
the investigation?
Conducting interviews with staff, residents and/or management:
Delineate the types of questions to ask in the interview.
2. Determining if the allegations are substantiated or
unsubstantiated: Identify criteria to determine if substantiated
or unsubstantiated.
How to develop a correction action plan. The plan may suggest:
A recommendation for a subsequent audit or follow-up to the
complaint and determination of when this is necessary.
A recommendation to refund any overpayments to federal
government, insurance company or individual payer and when
that may be the best course of action.
By
the due date assigned
, deliver your assignment to the
Submissions Area.
Use the following file naming convention:
LastnameFirstInitial_M5_A1.doc.
Assignment 1 Grading CriteriaMaximum Points
Discussed the process for reviewing the initial healthcare fraud
and abuse complaint and the items to look for to determine
validity.
-Explained the steps to take to determine who is involved in the
complaint.32Discussed how to obtain additional information to
develop a plan for the investigation and the items, which would
3. be important to the investigation.-
-Explained how to conduct interviews with staff, residents
and/or management and the types of questions to ask in the
interview.-
-32Identified the criteria to determine if the allegations are
substantiated or unsubstantiated.32Explained how to determine
when a recommendation for a subsequent audit or follow-up to
the complaint is necessary.
-Discussed the best course of action when a recommendation to
refund any overpayments to federal government, insurance
company or individual payer is warranted.
-Written Components
:
Style
(8 points): Tone, audience, and word choice
Organization
(16 points): Introduction, transitions, and conclusion
Usage and Mechanics
(16 points): Grammar, spelling, and sentence structure
APA Elements
(24 points): In text citations and references, paraphrasing, and
appropriate use of quotations and other elements of style
