This document discusses healthcare fraud, waste, and abuse compliance. It begins with a case study of United States v. Halper, where a medical laboratory manager submitted 65 false claims to Medicare, mischaracterizing services to receive higher reimbursements. It then defines fraud, waste, and abuse in healthcare. Fraud involves knowingly making false statements for an unauthorized benefit. Waste means unnecessary costs from overuse or misuse of services. Abuse refers to practices inconsistent with sound business that cause unnecessary costs. The document emphasizes the importance of compliance programs and policies to protect taxpayer dollars from fraud and divert funds to those who need care.

1. DEVELOPING
HEALTHCARE
FRAUD,WASTE
& ABUSE FOR
COMPLIANCE
BY MODUPE SARRATT
HCAD 640 9041
FIN MGMT FOR HEALTH CARE ORGS
UNIVERSITY OF MARYLAND UNIVERSITY COLLEGE

2. A Cited Case for Health Care Fraud is United States v. Halper
Respondent Irwin Halper worked as manager of New City Medical Laboratories, Inc.,
a company which provided medical service in New York City for patients eligible for
benefits under the federal Medicare program. In that capacity, Halper submitted to
Blue Cross and Blue Shield of Greater New York, a fiscal intermediary for Medicare,
65 separate false claims for reimbursement for service rendered. Specifically, on 65
occasions during 1982 and 1983, Halper mischaracterized the medical service
performed by New City, demanding reimbursement at the rate of $12 per claim
when the actual service rendered entitled New City to only $3 per claim. Duped by
these misrepresentations, Blue Cross overpaid New City a total of $585; Blue Cross
passed these overcharges along to the Federal Government.
The Government became aware of Halper's actions and in April 1985 it indicted him
on 65 counts of violating the criminal false-claims statute, 18 U. S. C. § 28
-- (1989).

3. Fraud, Waste and Abuse Compliance Policy
Healthcare Fraud, Waste and Abuse is estimated to add from 3% to 10% to all healthcare
spending. Unchecked fraud and abuse in our system can cost taxpayers billions of dollars each
year and divert critical healthcare dollars away from those who need the care. Protecting
government dollars used for healthcare is an important part of all of our jobs.
Definitions:
 FRAUD
– Is a false statement - made or submitted by an individual or entity - who knows
that the statement is false, and knows that the false statement could result in
some otherwise unauthorized benefit to the individual or entity. These false
statements could be verbal or written.
 WASTE
– Generally means over-use of services, or other practices that result in
unnecessary costs. In most cases, waste is not considered caused by reckless
actions but rather the misuse of resources
 ABUSE
– Generally refers to provider, contractor or member practices that are inconsistent
with sound business, financial or medical practices; and that cause unnecessary
costs to the healthcare system.
--Reference:2016 SHL Provider Summary Guide

4. ENFORCING THE STANDARD FOR NO FRAUD, WASTE, OR
ABUSE IS HEALTHCARE IS A HUMAN RIGHT
Healthcare is a human right
to medical services for:
 Health Information
 Medical Information
 Medical Treatment
 Health care services
 Medical Charges
 Insurance Payment for
health care & medical
care services.

5. MUST READ: DOUBLE CLICK THE ARTICLE

6. ALERT: TO THE LAW FOR COMPLIANCE PROGRAM
HOW DOES A PRACTICE GET STARTED?
B. The Compliance Review or "Legal Audit"
The foundation for a truly "effective" compliance plan is developed
before the compliance program
itself is designed and implemented. A rigorous "legal audit" or
compliance review accomplishes this
objective. The legal audit is nothing more than a comprehensive
internal investigation of the provider's
operations, generally focused on one or more targeted areas. The
purpose of the compliance review is to
ascertain whether the provider's current practices and procedures
conform with all pertinent legal
requirements. Such reviews particularly focus upon detecting any
potential violations of the Federal
Health Care Anti-kickback law, 42 U.S.C. § 1320a-7b(b), the civil
False Claims Act, 31 U.S.C. §§
3729-33, and pertinent regulations.
HEALTHCARE FRAUD COMPLIANCE PROGRAM
A. Healthcare Fraud Compliance Program is a federal
government law for the False Claims Act, that provide
the list of fraud under which its can recover damages plus
a penalty that ranges between $5,000 and $10,000 for
each fraudulent request for healthcare reimbursement.
(1) Federal criminal prosecutors can allege or charge for
kickbacks/bribes,
(2) mail fraud,
(3) making false statements in connection with claims
submitted to Medicare or state health programs,
(4) and conspiracies to defraud the government
(5) just to name a few pertinent criminal statutes.
Moreover, providers have come to dread a new player in
the enforcement game: qui tam law suits filed by
"whistleblowers" on behalf of the government who will
ultimately share as much as 30% of an
---Reference Fox & Clark 2000

7. AVOID FRAUD FOR ANTI-KICKBACK REGULATION
Reason to avoid Fraud is simple for retaliation of anti-kickback
regulations. According to Schencker (2016), the price to pay
outweighed the crime. The article for the penalties of fraud indicated
this:
Fraud penalties for healthcare providers and others will soon likely double,
according to an interim final rule published Thursday in the Federal Register.
Penalties for each false claim submitted to a government program, such as
Medicare, will rise to a minimum of $10,781 from a current minimum of
$5,500 under the False Claims Act. The maximum would rise to $21,563 per
claim from a current maximum of $11,000. It's not unusual for thousands of
claims to be at issue in a False Claims Act case, leading to the possibility of
total potential penalties in the millions and even billions of dollars.
According to the rule, penalties for violations of the Anti-Kickback law will also
rise from $11,000 to $21,563.
The avoid fraud requires a due diligence in the delegation of authority; because fraud is
tangled with the executives, who are entrusted to have the authority to make decisions

8. ARTICLE CITED FOR WRITTEN POLICIES,
PROCEDURES, & STANDARD OF CONDUCT
DOUBLE CLICK THE ARTICLE
FOR READING AFTER
ATTENDING THE TRAINING
IN SLIDE 16

9. HEALTHCARE FOR COMPLIANCE REQUIRE A VISION FOR
HEALTH & MEDICAL OPERATION
VISION
Treat to Cure for Practicing Medicine is the relationship between the Providers, the Patients, and the method of Payments:
 Healthcare is Human Right. To be treated for an illness. To be free from indebted to medical care or health care is receiving a
quality treatment for a reasonable price.
To avoid fraud, waste or abuse; providers & patients must compromise & compliance to ethics & what is reasonable & fair for
medical operation of rendering health care services & medical services
OPERATION
For the delivery of health and medical services & for Compliance to the policies is the Patient Statements for Care.
To determine what is necessary, affordable & what to charge for providing care by the provider
Would require the analysis for eliminating waste, to avoid fraud, & with removing any notion for possible abuse.
(Provider should note that a waste can be from patient requesting for unnecessary procedure & vise versa for provider
ordering unnecessary procedure)
While addressing the challenges for payment is applying the appropriate steps for complying to policy
With the diligent to report possible mistake or susceptible conduct of fraud
The view is an obstructer will be caught for discipline, never think of getting away with fraud or misconduct
for an individual undertaking a corrective action to change a wrong view or a wrong thought for an idea
When it comes to being caught for a fraud, a waste, or an abuse of a system, there is no excuse.

10. 7 SUGGESTIONS: FOR COMPLIANCE TO POLICIES
1. Affordable: reasonably priced to be inexpensive
2. Serviceable: in working order to fulfilling operational functions adequately
3. Flexible: capable of adjusting without breaking or suffering is ready and able to change so as to adapt to
different circumstances “You can save money if you’re flexible about where your room is located” is able to
save money when patient know what to buy for health care.
4. Multiple: is having options for variations of several elements associated with how services can be rendered
or adjusted to meet the patients ability for affordable care
5. Controllable: is statistics of comparison for checking the results of the alternatives to direct a situation for
manageable (if is not controllable, then is manageable with adjustable to patient ability to afford health
care.
6. Detectable: is capability to discover what can be done to solve a problem by identify the presence or
existence of an issue to expose the real or hidden nature of something is wrong to request or call for an
investigation
7. Transferable: is typical of financial assets, liabilities or legal right that is able to be transferred for auditing,

11. 7 SUGGESTIONS: FOR DELIVERY OF SERVICES
1. Expedite: is the protocol to process information that can be accomplished quickly.
2. Ensure: is making certain that information expedite occurs to be the case. To ensure
against any notion that information may be fraudulent is making sure that a problem
cannot occur with information provided.
3. Enhance: is to intensify, increase or further the quality of value information to the
extent there is no refutability or falsifiability
4. Eliminate: is completely remove any doubt for the policy that would eliminate
inflation in the course of providing health care. A guarantee for what a patient bought
for healthcare service is what he or she will get from the rendering of health care
service.
5. Improved: is make or becoming better with the used of healthcare information
technologies.
6. Increase: is the becoming of greater health service beyond the expectation of
requirement. The patient can make a change in the sales and profit margins for
health insurance. Patient can demand to lower the price of premium to increase
participation in buying health insurance.
7. Minimize: is reducing the unwanted or unpleasant of healthcare costs to keep down
the cost for reducing fraud

12. Understanding that FWA is an Individual Liability
Must Watch to know why: Double Click NASP

13. ENFORCING STANDARDS WITH WELL-PUBLICIZED
GUIDELINES
Relationship of Patients &
Providers
Explained with procedures &
management for charges
Correlation of Policies & Third
Parties
Explained with filling out the
Claim form for payments

14. Due Diligence in the Delegation of Authority is
Understanding Value-Based Healthcare
▪ By Cost for step 1
▪ By Charge for step 2
▪ By Payment for step 3
▪ For adapting to health care
policies and adjusting to the
third parties protocols are the
requisitions to examining step 2
& step 3 for the Value-Based
Healthcare.
Step 1: Cost
•To providers: is the expenses incurred to deliver care services to the patients
•To payers: the amount of health care coverage pay to the providers for services rendered by the
third party for patient health insurance
•To patients: the amount pay out-of-pocket for health care services.
Step 2: Charge or Price
•The amount asked by a provider for a health care good or service, which appears on patient
medical and health insurance claim (CMS-1500 Form)
•Providers price or charge are fixed for service rendered. However, charges are subject to
evaluation of services for customary, for the alternative, or if the service is requested, and
whether the service is necessary.
Step 3: Payment or the type of reimbursement
•A payment made by the third party to a provider for his or her services. That may be an amount
for every services delivered as “fee-for-service” in solo medical practice and Specialist practice.
•A payment made to the hospital for each day a patient is hospitalized for service is per diem for
“fee-for-stay” for each day that a patient is in the hospital plus
•A payment for each episode of diagnosing patient for a treatment, such as, while in the hospital
bed a patient call for pain medicine or for nurse attention is known for “diagnosis-relate group
charges or DRG” plus
•Payment for patient under the hospital care known as “capitation” because a patient in the
hospital is considered to be under the hospital care regardless whether the patient is receiving
treatment or not, the charges is every thing else included for monitoring patient while he or she
is still in hospital.
---- Reference: Arora et al (2015).The challenge of understanding health care costs and charges.

15. The Centers for Medicare & Medicaid Services
(“CMS”) modified certain rules and regulations of
the Medicare Advantage and the Part D programs
that state that a contractor’s compliance plan
must include training.

16. DOUBLE CLICK PRESENTING FOR ATTENDING THE
COLLABORATION TRAINING FOR FWA & COMPLIANCE
The Five Questions
1) WHAT IS A HEALTHCARE FRAUD
COMPLIANCE PROGRAM?
2) HOW CAN A PROVIDER DESIGN AND
IMPLMENT ONE?
3) WHY ARE COMPLIANCE PLANS
ESSENTIAL?
4) WHAT ARE THE ELEMENTS OF A
COMPLIANCE PROGRAM?
5) HOW DOES A PRACTICE GET STARTED?
PRESENTING
THE TRAINING FOR FRAUD,
WASTE & ABUSE.
DEVELOPED BY THE
CENTER FOR MEDICARE &
MEDICAID SERVICES

17. References
Arora, V., Moriates, C. & Shah, N. (2015). The challenge of understanding health care costs and charges. AMA Journal of Ethics, 17 (11): 1046-
1052. doi: 10.1001/journalofethics.2015.17.11.stas1-1511
Centers for Medicare & Medicaid Services. (2015). Medicare fraud & abuse: Prevention, detection, and reporting.
Fox, A., & Clark, R. H. (2000). What Is A Healthcare Fraud Compliance Program And How Can A Provider Design And Implement One?
Retrieved from file:///C:/Users/Admin/Downloads/Healthcare-Fraud-Compliance-Program%20(2).pdf
National Health Care Fraud Takedown Results (2016- https://t.co/LQk9OJpzKN pic.twitter.com/HMVFxvFrgd
— Justice Department (@TheJusticeDept) June 22, 2016
Schencker, L. (2016 June 30). Fraud, anti-kickback penalties to double.
Retrieved from http://www.modernhealthcare.com/article/20160630/NEWS/160639989
Sparrow, M. K. (1996). Health care fraud control: understanding the challenge. JOURNAL OF INSURANCE MEDICINE-NEW YORK-, 28, 86-
96.
United States v. Halper, 490 U.S. 435, 109 S. Ct. 1892, 104 L. Ed. 2d 487 (1989).
Retrieved from https://scholar.google.com/scholar_case?case=885240111461112288&q=MEDICARE+FRAUD+%26+ABU
SE:+PREVENTION,+DETECTION,+AND+REPORTING&hl=en&as_sdt=20000006