Fraud and abuse are significant problems in the Saudi Arabian healthcare system, with an estimated 10% of healthcare spending lost to such issues. Common problems include false billing, upcoding of charges, kickbacks between providers to refer patients, and falsifying medical records. The lack of transparency, regulations, and penalties have allowed these practices to become prevalent. In response, the Saudi government has established agencies like the Anti-Corruption Commission and implemented guidelines from SAMA for billing along with audits of providers. The Ministry of Health has also introduced electronic records and a fraud reporting system while establishing a department dedicated to investigating healthcare fraud cases.
The issue of fraud in health care has become a serious problem that every participant in the health delivery system must remain aware of in terms of potential and consequences. Managers in the health care system are tasked with ensuring that their staff members know the various fraud schemes as well as making sure that providers are not committing fraud themselves. A key way to accomplish this task is through education and training for fraud detection and prevention by and of health care stakeholders. The stakeholders in health care include providers, patients, organizations and institutions, the government, and the public. Also included are non-health care entities that may steal patient data for fraudulent claims and billing. Managers, therefore, are strongly advised to seek the services of health care compliance agencies to train staff, including doctors and nurses, on how to detect fraud and prevent fraud themselves. These agencies are also adept at helping to improve billing and payment functions to mitigate the risk of lost revenue through fraud and avoidance of criminal liability for the actions of providers and patients. The well-coordinated efforts of all stakeholders of health care assist in preserving the integrity of the system and make available quality services at reasonable prices for all.
Health 2.0 Conference Reviews Financial Impacts Of A Healthcare FraudHealth 2Conf
In this presentation, we will be understanding healthcare fraud and how it financially impacts the society as discussed at the upcoming healthcare event, the Health 2.0 Conference.
How To Detect And Prevent Healthcare Fraud? | Health 2.0 ConferenceHealth 2Conf
Take a look at the experts’ reviews from one of the most anticipated healthcare events in the USA, the Health 2.0 Conference, on how to detect as well as prevent oneself from healthcare fraud.
Are you aware of Medicare Fraud and Abuse?Jessica Parker
Most physicians strive to work ethically, provide high-quality medical care to their patients, and submit proper claims for payment. Trust is at the core of the physician-patient relationship. The Federal Government also places enormous trust in physicians. Medicare and other Federal health care programs rely on physicians’ medical judgment to treat patients with appropriate, medically necessary services.
1
8
Compliance Policies
Name
Course
Professor
Date
Compliance Policies
In the previous project, two compliance plans were developed and a job description developed for safety and compliance manager. However, strength for any compliance programs depends on compliance policy and procedurals which outlines applicable laws, regulations and standards that should be followed to implement developed plans. Compliance policies should be clear and simple to eliminate confusion or difficulties which may be experienced by implementers of compliance plans. Considering there are two compliance plans, to enhance clarity on the developed compliance, each compliance plan would be considered individually constituting two sections for two compliance policies under each compliance plan.
Compliance Plan For Covid protocols
The impact of Covid-19 has been felt in all sectors of economies and health sectors is not exceptional. Even though numerous professionals have been affected by the virus, significant healthcare providers have succumbed to the virus on the line of the duty. According to a study conducted that assess the impact of Covid-19 on the health sector, as of April 2020, countries that reported the significant number of healthcare providers that had succumbed to the virus are Italy with 44%, Iran with 15%, Philippines with 8%, Indonesia with 6%, and China, Spain, U.S each with 4% (Iyengar et al…,2020). Healthcare providers are the first line of defense at high risk of infection because they constantly engage and interact with Covid protocols. Given there is no cure for the virus, hospitals are implementing prevention measures to contain the spread of the virus, protect clients and also its staff. However, it has been noticed that staff members have been violating Covid protocols such as washing hands between patients necessitating the development of a Compliance plan for COVID. In the following two sections, compliance policies for the compliance plan for COVID are outlined.
Section 1: Compliance Standards for COVID Protocols
Healthcare providers should comply with standard precaution practices when treating patients regardless of the nature of diagnosis (Beyamo, Dodicho & Facha, 2019). In the healthcare facility, healthcare workers are at high risk of infection. Covid-19 is an infectious disease which means healthcare workers are at high risk of being exposed to the virus. For example, it is reported that more than 570,000 healthcare personnel had been infected with the virus in America (PAHO, 2020). This underscores need to take standard precaution which constitutes of policies which aimed at reducing the risk of transmitting infection in the healthcare (facility Beyamo et al…, 2019). Standard precautions are not selective to particular diseases because medical personal handles clients with a variety of infections.
To minimize the spread of Covid in the healthcare facility, standard precaution policies entail hand hygiene which requ ...
The issue of fraud in health care has become a serious problem that every participant in the health delivery system must remain aware of in terms of potential and consequences. Managers in the health care system are tasked with ensuring that their staff members know the various fraud schemes as well as making sure that providers are not committing fraud themselves. A key way to accomplish this task is through education and training for fraud detection and prevention by and of health care stakeholders. The stakeholders in health care include providers, patients, organizations and institutions, the government, and the public. Also included are non-health care entities that may steal patient data for fraudulent claims and billing. Managers, therefore, are strongly advised to seek the services of health care compliance agencies to train staff, including doctors and nurses, on how to detect fraud and prevent fraud themselves. These agencies are also adept at helping to improve billing and payment functions to mitigate the risk of lost revenue through fraud and avoidance of criminal liability for the actions of providers and patients. The well-coordinated efforts of all stakeholders of health care assist in preserving the integrity of the system and make available quality services at reasonable prices for all.
Health 2.0 Conference Reviews Financial Impacts Of A Healthcare FraudHealth 2Conf
In this presentation, we will be understanding healthcare fraud and how it financially impacts the society as discussed at the upcoming healthcare event, the Health 2.0 Conference.
How To Detect And Prevent Healthcare Fraud? | Health 2.0 ConferenceHealth 2Conf
Take a look at the experts’ reviews from one of the most anticipated healthcare events in the USA, the Health 2.0 Conference, on how to detect as well as prevent oneself from healthcare fraud.
Are you aware of Medicare Fraud and Abuse?Jessica Parker
Most physicians strive to work ethically, provide high-quality medical care to their patients, and submit proper claims for payment. Trust is at the core of the physician-patient relationship. The Federal Government also places enormous trust in physicians. Medicare and other Federal health care programs rely on physicians’ medical judgment to treat patients with appropriate, medically necessary services.
1
8
Compliance Policies
Name
Course
Professor
Date
Compliance Policies
In the previous project, two compliance plans were developed and a job description developed for safety and compliance manager. However, strength for any compliance programs depends on compliance policy and procedurals which outlines applicable laws, regulations and standards that should be followed to implement developed plans. Compliance policies should be clear and simple to eliminate confusion or difficulties which may be experienced by implementers of compliance plans. Considering there are two compliance plans, to enhance clarity on the developed compliance, each compliance plan would be considered individually constituting two sections for two compliance policies under each compliance plan.
Compliance Plan For Covid protocols
The impact of Covid-19 has been felt in all sectors of economies and health sectors is not exceptional. Even though numerous professionals have been affected by the virus, significant healthcare providers have succumbed to the virus on the line of the duty. According to a study conducted that assess the impact of Covid-19 on the health sector, as of April 2020, countries that reported the significant number of healthcare providers that had succumbed to the virus are Italy with 44%, Iran with 15%, Philippines with 8%, Indonesia with 6%, and China, Spain, U.S each with 4% (Iyengar et al…,2020). Healthcare providers are the first line of defense at high risk of infection because they constantly engage and interact with Covid protocols. Given there is no cure for the virus, hospitals are implementing prevention measures to contain the spread of the virus, protect clients and also its staff. However, it has been noticed that staff members have been violating Covid protocols such as washing hands between patients necessitating the development of a Compliance plan for COVID. In the following two sections, compliance policies for the compliance plan for COVID are outlined.
Section 1: Compliance Standards for COVID Protocols
Healthcare providers should comply with standard precaution practices when treating patients regardless of the nature of diagnosis (Beyamo, Dodicho & Facha, 2019). In the healthcare facility, healthcare workers are at high risk of infection. Covid-19 is an infectious disease which means healthcare workers are at high risk of being exposed to the virus. For example, it is reported that more than 570,000 healthcare personnel had been infected with the virus in America (PAHO, 2020). This underscores need to take standard precaution which constitutes of policies which aimed at reducing the risk of transmitting infection in the healthcare (facility Beyamo et al…, 2019). Standard precautions are not selective to particular diseases because medical personal handles clients with a variety of infections.
To minimize the spread of Covid in the healthcare facility, standard precaution policies entail hand hygiene which requ ...
Potential factor of rising health care cost. Presentation will drive around introduction,facts, statistics, tactics and solutions regarding fraud & abuse. I would like to thank Imran Bhai for his suggestions
The Importance Of Accurate Charge Entry In Medical Billing Avoiding Costly E...Richard Smith
Effective medical billing is essential for healthcare organizations to maintain financial stability and ensure accurate reimbursement. One critical aspect of the medical billing process is accurate charge entry. Accurate charge entry involves meticulously recording the services provided to patients, along with their corresponding charges.
The Importance Of Accurate Charge Entry In Medical Billing Avoiding Costly E...Richard Smith
Effective medical billing is essential for healthcare organizations to maintain financial stability and ensure accurate reimbursement. One critical aspect of the medical billing process is accurate charge entry.
Automated Obligation Management to Reduce Fraud RIsks in Healthcare Provider ...Aavenir
Common types of healthcare fraud include:
• Billing for no-show appointments
• Submitting claims for services at a higher complexity and higher claim reimbursement levels than presented
or documented
• Billing for services not provided, and payments made for referrals
Regulatory compliance obligations govern all agreements in the healthcare world. Such regulations include
HIPAA, Stark I, II, III; False Claims, HITECH, Federal Anti-Kickback Statute, and JCAHO to name a few.
Can implementing the healthcare obligation management and compliance solutions combat the risks of healthcare fraud?
The Challenges Of Investigating Healthcare Fraud Cases | Health 2.0 ConferenceHealth 2Conf
In this presentation, we will be taking a look at the challenges faced during investigating a healthcare fraud, scams, and spam, as reviewed by the experts at the leading healthcare conferences of 2023, the Health 2.0 Conference.
Côte d’Ivoire Stronger Health Governance to Fight Emerging Health EmergenciesHFG Project
Cote d'Ivoire's Institute National d'Hygiene Publique (INHP) coordinates the country's Ebola response and oversees the prevention, detection, and response to other emerging disease threats. Recently, INHP and the Ministry of Health identified financial control and audit tools as critical components in health emergency preparedness.
Understanding Health Accounts: A Primer for PolicymakersHFG Project
An update of the 2003 brief, this new primer provides an introduction to Health Accounts, the framework (System of Health Accounts 2011 or SHA 2011), and key steps involved in conducting Health Accounts exercises using SHA 2011 with particular emphasis on how policymakers can get involved to facilitate the process. The primer also includes country experiences illustrating show how Health Accounts data can be used for policy purposes, with specific attention to the importance of institutionalizing Health Accounts so that it may serve as an ongoing resource to policymakers.
As part of the government’s national strategy, the United Arab Emirates is seeking to raise the quality of healthcare to international best practice standards by 2021. What are the main quality gaps to be overcome in this period? How are changes such as mandatory insurance laws, management outsourcing of public facilities, regulatory devolution and increased rates of accreditation and data collection influencing quality of care?
Health Insurance Fraud | Health 2.0 Conference suggests ways to protect yours...Health 2Conf
The presentation by the Health 2.0 Conference takes through the proliferation of the health care sector: Health insurance fraud and how it affects the consumer. Through this presentation, you will get a chance to learn about what is health insurance fraud, scams, and spam, the common types of health insurance fraud, and how attending the conference will suggest ways to protect you from health insurance scams.
1) Discuss some common causes for coding errors and the preventati.docxswannacklanell
1)
Discuss some common causes for coding errors and the preventative measures you can use to avoid them.
2)
What are some other measures you can add to the list that might not be in the course materials?
3)
What is the Fraud and Abuse Control Program? What is the HHS OIG and what is it's major concern?
(Be sure to watch the video below.)
Watch Video
A
Roadmap
for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse
http://www.youtube.com/watch?v=0yRo-YmITus
The video summarizes the five main Federal fraud and abuse laws (the False Claims Act, the Anti-Kickback Statute, the Stark Law, the Exclusion Statute, and the Civil Monetary Penalties Law) and provide tips on how physicians should comply with these laws in their relationships with payers (e.g., the Medicare and Medicaid programs), vendors (e.g., drug, biologic, and medical device companies), and fellow providers (e.g., hospitals, nursing homes, and physician colleagues).
Please review the discussion board rubric found under "Start Here".
Use
in-text citations
appropriately and provide
full citations for your initial post and at least one of your response posts.
One of your citations needs to be
outside
of your text.
The idea is that you would not only comment on your classmate's post but also do some additional research furthering the discussion.
To begin discussing in this forum, click the forum title, "Week 3 Discussion". Then, click Create Thread on the Action Bar to post your initial reply. To reply to a fellow participant, click the title of the initial post, then click Reply.
Quetsy Garcia
discussion week 3
Collapse
Total views: 1 (Your views: 1)
These are some of the most common causes for coding errors:
Incorrect coding
Upcoding
Unbundling of services
Billing for medically unnecessary services
Billing for services not covered under health plan
Duplicate billing
What are some other measures you can add to the list that might not be in the course materials?
Reviewing to assure there is no incorrect information for the patient (name, sex, date of birth, insurance ID information, etc.)
Assuring insurance provider information is accurate (policy numbers, address, contact information, etc.)
Inputting the wrong codes or confusing codes such as CPT codes, point of service codes, or ICD-9-CM codes
Entering too few or too many digits for ICD-9-CM codes
Inputting mismatched treatment and diagnostic codes
Forgetting to input codes at all for services performed by a physician or another healthcare official
Not having access to EOBs on denied claims
Not verifying a patient’s insurance coverage
What is the Fraud and Abuse Control Program? What is the HHS OIG and what is it’s main concern?
HHS is a Fraud and Abuse Control Program
OIG carries out nationwide audits and investigations. They have the authority to investigate basically any healthcare facility.
There primarily concern is to make sure business comply with principles of business practice and avoid he ...
Potential factor of rising health care cost. Presentation will drive around introduction,facts, statistics, tactics and solutions regarding fraud & abuse. I would like to thank Imran Bhai for his suggestions
The Importance Of Accurate Charge Entry In Medical Billing Avoiding Costly E...Richard Smith
Effective medical billing is essential for healthcare organizations to maintain financial stability and ensure accurate reimbursement. One critical aspect of the medical billing process is accurate charge entry. Accurate charge entry involves meticulously recording the services provided to patients, along with their corresponding charges.
The Importance Of Accurate Charge Entry In Medical Billing Avoiding Costly E...Richard Smith
Effective medical billing is essential for healthcare organizations to maintain financial stability and ensure accurate reimbursement. One critical aspect of the medical billing process is accurate charge entry.
Automated Obligation Management to Reduce Fraud RIsks in Healthcare Provider ...Aavenir
Common types of healthcare fraud include:
• Billing for no-show appointments
• Submitting claims for services at a higher complexity and higher claim reimbursement levels than presented
or documented
• Billing for services not provided, and payments made for referrals
Regulatory compliance obligations govern all agreements in the healthcare world. Such regulations include
HIPAA, Stark I, II, III; False Claims, HITECH, Federal Anti-Kickback Statute, and JCAHO to name a few.
Can implementing the healthcare obligation management and compliance solutions combat the risks of healthcare fraud?
The Challenges Of Investigating Healthcare Fraud Cases | Health 2.0 ConferenceHealth 2Conf
In this presentation, we will be taking a look at the challenges faced during investigating a healthcare fraud, scams, and spam, as reviewed by the experts at the leading healthcare conferences of 2023, the Health 2.0 Conference.
Côte d’Ivoire Stronger Health Governance to Fight Emerging Health EmergenciesHFG Project
Cote d'Ivoire's Institute National d'Hygiene Publique (INHP) coordinates the country's Ebola response and oversees the prevention, detection, and response to other emerging disease threats. Recently, INHP and the Ministry of Health identified financial control and audit tools as critical components in health emergency preparedness.
Understanding Health Accounts: A Primer for PolicymakersHFG Project
An update of the 2003 brief, this new primer provides an introduction to Health Accounts, the framework (System of Health Accounts 2011 or SHA 2011), and key steps involved in conducting Health Accounts exercises using SHA 2011 with particular emphasis on how policymakers can get involved to facilitate the process. The primer also includes country experiences illustrating show how Health Accounts data can be used for policy purposes, with specific attention to the importance of institutionalizing Health Accounts so that it may serve as an ongoing resource to policymakers.
As part of the government’s national strategy, the United Arab Emirates is seeking to raise the quality of healthcare to international best practice standards by 2021. What are the main quality gaps to be overcome in this period? How are changes such as mandatory insurance laws, management outsourcing of public facilities, regulatory devolution and increased rates of accreditation and data collection influencing quality of care?
Health Insurance Fraud | Health 2.0 Conference suggests ways to protect yours...Health 2Conf
The presentation by the Health 2.0 Conference takes through the proliferation of the health care sector: Health insurance fraud and how it affects the consumer. Through this presentation, you will get a chance to learn about what is health insurance fraud, scams, and spam, the common types of health insurance fraud, and how attending the conference will suggest ways to protect you from health insurance scams.
1) Discuss some common causes for coding errors and the preventati.docxswannacklanell
1)
Discuss some common causes for coding errors and the preventative measures you can use to avoid them.
2)
What are some other measures you can add to the list that might not be in the course materials?
3)
What is the Fraud and Abuse Control Program? What is the HHS OIG and what is it's major concern?
(Be sure to watch the video below.)
Watch Video
A
Roadmap
for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse
http://www.youtube.com/watch?v=0yRo-YmITus
The video summarizes the five main Federal fraud and abuse laws (the False Claims Act, the Anti-Kickback Statute, the Stark Law, the Exclusion Statute, and the Civil Monetary Penalties Law) and provide tips on how physicians should comply with these laws in their relationships with payers (e.g., the Medicare and Medicaid programs), vendors (e.g., drug, biologic, and medical device companies), and fellow providers (e.g., hospitals, nursing homes, and physician colleagues).
Please review the discussion board rubric found under "Start Here".
Use
in-text citations
appropriately and provide
full citations for your initial post and at least one of your response posts.
One of your citations needs to be
outside
of your text.
The idea is that you would not only comment on your classmate's post but also do some additional research furthering the discussion.
To begin discussing in this forum, click the forum title, "Week 3 Discussion". Then, click Create Thread on the Action Bar to post your initial reply. To reply to a fellow participant, click the title of the initial post, then click Reply.
Quetsy Garcia
discussion week 3
Collapse
Total views: 1 (Your views: 1)
These are some of the most common causes for coding errors:
Incorrect coding
Upcoding
Unbundling of services
Billing for medically unnecessary services
Billing for services not covered under health plan
Duplicate billing
What are some other measures you can add to the list that might not be in the course materials?
Reviewing to assure there is no incorrect information for the patient (name, sex, date of birth, insurance ID information, etc.)
Assuring insurance provider information is accurate (policy numbers, address, contact information, etc.)
Inputting the wrong codes or confusing codes such as CPT codes, point of service codes, or ICD-9-CM codes
Entering too few or too many digits for ICD-9-CM codes
Inputting mismatched treatment and diagnostic codes
Forgetting to input codes at all for services performed by a physician or another healthcare official
Not having access to EOBs on denied claims
Not verifying a patient’s insurance coverage
What is the Fraud and Abuse Control Program? What is the HHS OIG and what is it’s main concern?
HHS is a Fraud and Abuse Control Program
OIG carries out nationwide audits and investigations. They have the authority to investigate basically any healthcare facility.
There primarily concern is to make sure business comply with principles of business practice and avoid he ...
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Thanks for contributing to our discussion on fraud and Kickbacks.docx
1. Thanks for contributing to our discussion on fraud and abuse. Kickbacks
are an i
Thanks for contributing to our discussion on fraud and abuse. Kickbacks are an interesting
type of abuse. What are the negative consequences when it comes to patient care? What
kind of regulatory response might help mitigate the impact and prevalence of
kickbacks?Warmly,Dr. Heatherthis is my discusstionFraud and Abuse in
HealthcareHealthcare fraud and abuse are significant concerns in Saudi Arabia. It is
estimated that up to 10% of all healthcare spending in the country is lost to fraud and
abuse, which can have a devastating effect on the quality of care for patients, financial losses
for healthcare providers, and increased costs for the government (Alonazi, 2020). There are
several fraud and abuse issues in the Kingdom of Saudi Arabia, including false billing and
upcoding, falsification of medical records, kickbacks, and bribery.False billing and upcoding
occur when healthcare providers charge for services that were not provided or exaggerate
the complexity of services offered to receive higher reimbursement rates. The article
suggests that false billing and upcoding are prevalent in KSA due to the need for more
transparency in billing systems and inadequate auditing. Kickbacks and bribery are
common in KSA, where healthcare providers pay or receive money or gifts to refer patients
to specific providers or to prescribe certain drugs or medical devices. The article argues that
the lack of regulations and clear penalties for such practices contribute to their
prevalence.Falsifying medical records involves the creation of false or misleading medical
records to justify unnecessary procedures or treatments or to cover up malpractice. The
article states that falsification of medical records is prevalent in KSA, where healthcare
providers have reported being pressured by their superiors to falsify records to avoid legal
repercussions.The Saudi Arabian government has implemented several regulatory and
governmental efforts to reduce healthcare fraud and abuse. One such effort is the
establishment of the Saudi Arabian Anti-Corruption Commission (Nazaha) in 2011, which is
responsible for investigating and prosecuting cases of corruption and fraud in all sectors,
including healthcare (Ahmed, 2021). Additionally, the Saudi Arabian Monetary Agency
(SAMA) has established guidelines for healthcare providers to follow when submitting
claims for reimbursement to insurance companies or government programs. SAMA also
conducts regular audits of healthcare providers to detect fraudulent billing
practices.Furthermore, the Saudi Arabian Ministry of Health has implemented several
initiatives to reduce healthcare fraud and abuse, including introducing electronic medical
2. records and implementing a system for reporting and investigating suspected fraud and
abuse cases. The Ministry of Health has also established a department dedicated to
exploring and prosecuting healthcare fraud and abuse cases.ReferencesAhmed, S. Z. (2021).
An Evaluation of the Anti-Fraud Regime in Saudi Arabia from the Islamic Shariah
Perspective. Universal Journal of Business and Management, 94-120.Alonazi, W. B. (2020).
Fraud and abuse in the Saudi healthcare system: a triangulation analysis. INQUIRY: The
Journal of Health Care Organization, Provision, and Financing, 57, 0046958020954624.
