4-2 Responses 1. Re: Topic 4 DQ 2 Fraud and negligence are closely related. Negligent behaviors include acts of commission and omission. "Commission of an act would include...performing the wrong surgical procedure" (Pozgar & Santucci, 2016, p. 65). Some examples related to the previous statement are: performing unnessary surgeries on patients under Medicare, signing prescriptions for patients never seen, or inflating charges for inpatient or outpatient care (Rudman, et al, 2009). This includes inflating insurance claims and false reporting/charting. "Healthcare fraud is defined as knowingly, and willfully executing or attempting to execute a scheme...to defraud any healthcare benefit program or to obtain by means of false or fradulent pretenses, representations, or promises any of the money or property owned...by any healthcare benefit program" (Rudman, et al, 2009). The Stark Law and Antikickback Statute help prevent physician fraud. "Abuse is similar to fraud, except that the investigator cannot establish the act knowingly, willingly, and intentionally" (Rudman, et al, 2009). A form of abuse is abandonment. "It can be the result of a personality conflict or pure negligence in following up on the patient's care needs" (Pozgar & Santucci, 2016, p. 249). Simply inadequate care, such as not seeing a patient daily, can also be a form of abuse (Pozgar & Santucci, 2016, p. 254). Performing unnecessary medical tests is abuse. Physical forms of abuse include unnecessary restraints, forcible medication administration, and literal verbal or physical abuse to patients. A compliance committee serves to help a healthcare facillity adhere to federal, state, and local regulations, as well as hospital policies. They can also serve as educators and advisors for billing, payments, and all patient documentation. As educators, they can provide hospital staff with continuing education and updates on regulation compliance. Because there are so many regulations in healthcare, a committee is not only helpful, but necessary. It is a big job, and their main role should be education. Education is the best way to prevent errors. Pozgar, G. D., & Santucci, N. M. (2016). Legal Aspects of Health Care Administration. (12th ed). Burlington, MA: Jones & Bartlett Learning. Rudman, W. J., Eberhardt, J. S., 3rd, Pierce, W., & Hart-Hester, S. (2009). Healthcare fraud and abuse. Perspectives in health information management, 6(Fall), 1g. 2. Fraudulent or abusive behavior in health care is when a provider or consumer intentionally submits, or is the cause of someone else submitting, false or misleading information to determine the amount of payable healthcare benefits. Some of these behaviors or actions include: fraudulent billing for services that were not delivered; falsifying diagnosis’s for unnecessary tests, surgeries, or other procedures; misrepresentation of procedures for the purpose of billing for services that would not otherwise be covered (such .

1. 4-2 Responses
1.
Re: Topic 4 DQ 2
Fraud and negligence are closely related. Negligent behaviors
include acts of commission and omission. "Commission of an
act would include...performing the wrong surgical procedure"
(Pozgar & Santucci, 2016, p. 65). Some examples related to the
previous statement are: performing unnessary surgeries on
patients under Medicare, signing prescriptions for patients
never seen, or inflating charges for inpatient or outpatient care
(Rudman, et al, 2009). This includes inflating insurance claims
and false reporting/charting. "Healthcare fraud is defined as
knowingly, and willfully executing or attempting to execute a
scheme...to defraud any healthcare benefit program or to obtain
by means of false or fradulent pretenses, representations, or
promises any of the money or property owned...by any
healthcare benefit program" (Rudman, et al, 2009). The Stark
Law and Antikickback Statute help prevent physician fraud.
"Abuse is similar to fraud, except that the investigator cannot
establish the act knowingly, willingly, and intentionally"
(Rudman, et al, 2009). A form of abuse is abandonment. "It can
be the result of a personality conflict or pure negligence in
following up on the patient's care needs" (Pozgar & Santucci,
2016, p. 249). Simply inadequate care, such as not seeing a
patient daily, can also be a form of abuse (Pozgar & Santucci,
2016, p. 254). Performing unnecessary medical tests is abuse.
Physical forms of abuse include unnecessary restraints, forcible
medication administration, and literal verbal or physical abuse
to patients.
A compliance committee serves to help a healthcare facillity
adhere to federal, state, and local regulations, as well as
hospital policies. They can also serve as educators and advisors

2. for billing, payments, and all patient documentation. As
educators, they can provide hospital staff with continuing
education and updates on regulation compliance. Because there
are so many regulations in healthcare, a committee is not only
helpful, but necessary. It is a big job, and their main role should
be education. Education is the best way to prevent errors.
Pozgar, G. D., & Santucci, N. M. (2016). Legal Aspects of
Health Care Administration. (12th ed). Burlington, MA:
Jones & Bartlett Learning.
Rudman, W. J., Eberhardt, J. S., 3rd, Pierce, W., & Hart-Hester,
S. (2009). Healthcare fraud and abuse.
Perspectives in health information management, 6(Fall),
1g.
2.
Fraudulent or abusive behavior in health care is when a provider
or consumer intentionally submits, or is the cause of someone
else submitting, false or misleading information to determine
the amount of payable healthcare benefits. Some of these
behaviors or actions include: fraudulent billing for services that
were not delivered; falsifying diagnosis’s for unnecessary tests,
surgeries, or other procedures; misrepresentation of procedures
for the purpose of billing for services that would not otherwise
be covered (such as cosmetic surgery); upcoding services;
upcoding medical supplies; unbundling (billing for procedures
separately); billing unnecessary services; accepting kickbacks
for referrals; and overbilling (Pozgar & Santucci, 2016).
The responsibilities of a compliance committee include
developing auditing policies and procedures to prevent, detect,
deter, and report fraud. Safeguarding assets and ensuring that
the functions of financial reporting are kept up with acceptable
accounting principles, as well as reviewing and determining the
reliability and integrity of the financial and operating
information. If the committee fails to question representations,
it could result in committee malfeasance and the committee

3. could be held liable for failure to understand and know what
they are responsible for identifying (Pozgar & Santucci, 2016).
Pozgar, G.D. & Santucci, N.M. (2016). Legal Aspects of Health
Care Administration (12th ed.). Burlington, MA: Jones &
Bartlett Learning.
3.
1 posts
Re: Topic 4 DQ 2
Healthcare fraud and abuse cases cost the industry billions of
dollars a year. Without processes in place to detect and prevent
fraudulent activities, healthcare providers could face an
investigation that may cost them their reputation and revenue.
Fraud is defined as knowingly, and willfully executes or
attempts to execute a scheme. Abuse is defined in terms of acts
that are inconsistent with sound medial or business practice.
Abuse is an unintentional practice that directly or indirectly
results in an overpayment to the healthcare provider. Abuse is
similar to fraud, the difference is that anyone investigating the
“act” cannot establish if the act was committed knowingly,
willfully, and intentionally. The term “intentional” is extremely
important in defining abuse, fraud, ethical or unethical action
(Rudman, 2009),
Healthcare fraud is committed when a dishonest provider or
consumer intentionally submits or causes someone else to
submit false or misleading information for use in determining
the amount of healthcare benefits payable (Pozgar & Santucci,
2016, pg. 104-105).
Examples of fraud and abuse in healthcare range from:
Intentional misrepresentation of services that result in higher
payments
Billing of unperformed services
The deliberate delivery of unnecessary and inappropriate

4. services for the express purpose of receiving the payment
Inflating Insurance Claim,
Fraudulent Billing,
Pharmacist submitting false drug claims
Physician billing for services not rendered
Fraudulent billing for laboratory tests
The way that the compliance committee helps to monitor and
prevent fraud and abuse in the health care industry start by
implementing comprehensive compliance programs by having to
take a look at the program and see how it is designed, how is it
structured, and is it a real compliance program being practice.
This will allow investigators, auditors, administrator do their
jobs.
References:
Pozgar, G.D. & Santucci, N.M. (2016). Legal Aspects of Health
Care Administration (12th ed.). Burlington, MA: Jones &
Bartlett Learning.
Rudman, W. J., Eberhardt, J. S., 3rd, Pierce, W., & Hart-Hester,
S. (2009). Healthcare fraud and abuse. Perspectives in health
information management, 6(Fall), 1g.
Rubic_Print_FormatCourse CodeClass CodeHLT-520HLT-520-
O500EMTALA Scenario
Analysis80.0CriteriaPercentageUnsatisfactory (0.00%)Less
Than Satisfactory (65.00%)Satisfactory (75.00%)Good
(85.00%)Excellent (100.00%)CommentsPoints
EarnedContent70.0%EMTALA Violations 20.0%A description
of EMTALA violations if the patient was rejected is not
included. A description of EMTALA violations if the patient
was rejected is incomplete or incorrect.A description of
EMTALA violations if the patient was rejected is included, but
lacks supporting detail.A description of EMTALA violations if
the patient was rejected is complete and includes supporting
detail. A description of EMTALA violations if the patient was
rejected is extremely thorough with substantial supporting
detailAdministrator Decision20.0%A description of the

5. administrators decision is not included. A description of the
administrators decision is incomplete or incorrect.A description
of the administrators decision is included, but lacks supporting
detail.A description of the administrators decision is complete
and includes supporting detail.A description of the
administrators decision is extremely thorough with substantial
supporting detail.Prevention Strategies15.0%An explanation of
potential prevention strategies is not included. An explanation
of potential prevention strategies is incomplete or incorrect.An
explanation of potential prevention strategies is included, but
lacks supporting detail.An explanation of potential prevention
strategies is complete and includes supporting detail.An
explanation of potential prevention strategies is extremely
thorough with substantial supporting detail.EMTALA Concerns
15.0%A description of possible concerns related to EMTALA is
not includedA description of possible concerns related to
EMTALA is incomplete or incorrect.A description of possible
concerns related to EMTALA is included, but lacks supporting
detail.A description of possible concerns related to EMTALA is
complete and includes supporting detail.A description of
possible concerns related to EMTALA is extremely thorough
with substantial supporting detail.Organization and
Effectiveness20.0%Thesis Development and Purpose7.0%Paper
lacks any discernible overall purpose or organizing
claim..Thesis is insufficiently developed or vague. Purpose is
not clear.Thesis is apparent and appropriate to purpose.Thesis is
clear and forecasts the development of the paper. Thesis is
descriptive and reflective of the arguments and appropriate to
the purpose.Thesis is comprehensive and contains the essence of
the paper. Thesis statement makes the purpose of the paper
clear.Argument Logic and Construction8.0%Statement of
purpose is not justified by the conclusion. The conclusion does
not support the claim made. Argument is incoherent and uses
noncredible sources.Sufficient justification of claims is lacking.
Argument lacks consistent unity. There are obvious flaws in the
logic. Some sources have questionable credibility.Argument is

6. orderly, but may have a few inconsistencies. The argument
presents minimal justification of claims. Argument logically,
but not thoroughly, supports the purpose. Sources used are
credible. Introduction and conclusion bracket the thesis.
Argument shows logical progressions. Techniques of
argumentation are evident. There is a smooth progression of
claims from introduction to conclusion. Most sources are
authoritative.Clear and convincing argument that presents a
persuasive claim in a distinctive and compelling manner. All
sources are authoritative.Mechanics of Writing (includes
spelling, punctuation, grammar, language use)5.0%Surface
errors are pervasive enough that they impede communication of
meaning. Inappropriate word choice or sentence construction is
used.Frequent and repetitive mechanical errors distract the
reader. Inconsistencies in language choice (register) or word
choice are present. Sentence structure is correct but not
varied.Some mechanical errors or typos are present, but they are
not overly distracting to the reader. Correct and varied sentence
structure and audience-appropriate language are employed.Prose
is largely free of mechanical errors, although a few may be
present. The writer uses a variety of effective sentence
structures and figures of speech.Writer is clearly in command of
standard, written, academic English.Format10.0%Paper Format
(use of appropriate style for the major and
assignment)5.0%Template is not used appropriately or
documentation format is rarely followed correctly.Appropriate
template is used, but some elements are missing or mistaken. A
lack of control with formatting is apparent.Appropriate template
is used. Formatting is correct, although some minor errors may
be present. Appropriate template is fully used. There are
virtually no errors in formatting style.All format elements are
correct. Documentation of Sources (citations, footnotes,
references, bibliography, etc., as appropriate to assignment and
style)5.0%Sources are not documented.Documentation of
sources is inconsistent or incorrect, as appropriate to
assignment and style, with numerous formatting errors.Sources

7. are documented, as appropriate to assignment and style,
although some formatting errors may be present.Sources are
documented, as appropriate to assignment and style, and format
is mostly correct. Sources are completely and correctly
documented, as appropriate to assignment and style, and format
is free of error.Total Weightage100%