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:

1. How to conduct an investigation.  It should include the following elements:

 

1. Reviewing the initial complaint: What are the items you should look for in a compliant to determine validity?
2. 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?
3. Obtaining additional information as necessary and developing a plan for the investigation:  What other items are important to the investigation?
4. Conducting interviews with staff, residents and/or management: Delineate the types of questions to ask in the interview.
5. Determining if the allegations are substantiated or unsubstantiated: Identify criteria to determine if substantiated or unsubstantiated.

 

1. How to develop a correction action plan. The plan may suggest: 

 

1. A recommendation for a subsequent audit or follow-up to the complaint and determination of when this is necessary.
2. A recommendation to refund any overpayments to federal government, insurance company or individual payer and when that may be the best course of action.

 

 

Assignment 1 Grading Criteria 

Maximum Points

Discussed the process for reviewing the initial healthcare fraud and abuse complaint and the items to look for to determine validity.

36

Explained the steps to take to determine who is involved in the complaint.

32

Discussed how to obtain additional information to develop a plan for the investigation and the items, which would be important to the investigation.

32

Explained how to conduct interviews with staff, residents and/or management and the types of questions to ask in the interview.

32

Identified the criteria to determine if the allegations are substantiated or unsubstantiated.

32

Explained how to determine when a recommendation for a subsequent audit or follow-up to the complaint is necessary.

36

Discussed the best course of action when a recommendation to refund any overpayments to federal government, insurance company or individual payer is warranted.

36

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

64

Total:

300