Application Exercise:
1. Locate the current Office of Inspector General Work Plan on the Health and Human Services Office of Inspector General website. Write a memo to your Compliance Officer outlining the key areas for your inpatient facility. Identify which areas would be appropriate for the auditing schedule, which areas would be appropriate for the education schedule, and which areas would be appropriate for both schedules.
2. Visit the Medicare CERT homepage. Locate the most recent CERT annual report. Use Appendix B: Projected Improper Payments and Type of Error by Type of Service for each Claim Type to identify the top issue for the following claim types: Part B, DMEPOS, Part A excluding Inpatient Hospital PPS and Part A Inpatient Hospital PPS. For each claim type identify the top issue (for Part A Inpatient Hospital PPS identify the top clinical area). For each top issue identify the payment implication, the error rate, and the most significant error type.
Real-World Case Study
In the Real-World Case in chapter 1 of the Student Workbook, students investigated consumer-related topics on the websites of the states' insurance commissions. A common topic was reporting fraud. Additionally, in chapter 2 of the textbook, fraud and abuse in healthcare reimbursement were discussed as they related to Medicare and Medicaid. However, personnel in health organizations should also be aware that fraud and abuse exist in the voluntary health insurance sector.
Fraud is the intent to deceive in order to gain an unfair or undeserved advantage or benefit. Healthcare fraud is widespread (Rosenbaum et al. 2009, 1). Examples of fraud include fraudulent billing, kickbacks, upcoding, and ghost patients (Rosenbaum et al. 2009, 2). As can be deduced from the examples, most people who commit fraud are healthcare providers.
Q1. Does your state insurance commission provide information about insurance fraud?
Q2. Does your state have multiple means to notify the commission of insurance fraud?
Q3. Does your state give examples of common types of insurance frauds?
Please in-text citation and references are a must