Healthcare Fraud Case Study

I will discuss why fraud occurs and discuss policies and actions at my hospital to prevent fraud, acting as a CEO of a hospital. No research is needed to tell anyone that the greed of money is the major reason why any sort of fraud occurs. In the healthcare industry, physicians, hospital administrators, and other healthcare professionals commit fraud by receiving kickbacks for unprovided goods and services. According to the Centers for Disease Control and Prevention (CDC), “health care fraud perpetrators steal billions of dollars each year from Federal and State governments, from American taxpayers, and some of our country’s most vulnerable citizens” (2013, para. 1). It is my job to ensure my hospital is in accordance with anti-fraud laws
and ensure that my hospital is aware of fraud prevention.

One policy that I will put in place has all employees participate in a fraud prevention training program.
Based on previous research, the Centers for Medicare & Medicaid Services (CMS) has a resource, Medicare Learning Network, which includes web-based training classes that offer continuing education credits. For example, physicians will be required to participate in the Avoiding Medicare Fraud & Abuse: A Roadmap for Physicians web-based training, which instructs physicians how to stay in compliance with fraud and abuse laws (Centers for Medicare & Medicaid Services, 2017). Additionally, all employees that are affected by anti-fraud laws will be required to take part in the Medicare Fraud & Abuse: Prevention, Detection, and Reporting web-based training, in which health care professionals learn fraud and abuse laws, who regulates these laws, and how to report fraud and abuse (2017). I will ensure that all employees are aware that detecting and reporting fraud and abuse are just as important as prevention. Moreover, employees are subject to reprimanding if they do not report suspicion or actually knowing of another employee engaging in
fraud.

Furthermore, I will produce a policy that will remain in the policy and procedure manuals that are located throughout the hospital. Many hospitals have corporate compliance policies in place for fraud prevention. For instance, Jefferson University Hospitals has a policy named Preventing Fraud, Waste and Abuse and the Federal False Claims Act, whose purpose is “to provide all employees, contractors, and agents of TJUH with detailed information regarding federal and state laws relating to false claims, including whistleblower provision in those laws, and to also provide information on preventing and detecting fraud, waste, and abuse in the health care industry” (Jefferson University Hospitals, 2014, para. 1). Once an employee signs a form that they have received a written copy of a policy, that will similar to that of Jefferson University Hospitals, then they are liable to penalties for violating the policy.

Additionally, the employee handbook will include actions that the hospital will take against individuals that knowingly and willfully commit health care fraud, or are aware of others that commit fraud and do not report it. Fraud is illegal and will result in immediate termination. Most organizations, including my own, do not want to be affiliated with dishonest people, therefore second chances for fraud and abuse are unwarranted.

In conclusion, hospital administrators have a tough task with fraud compliance. Money, or rather the greed for money, is a tough opponent to fight. The biblical saying, “money is the root of all evil,” was evident in biblical times and continues to be evident today, even in the healthcare industry. Mandating fraud prevention training and enforcing fraud violations are necessary for hospitals to operate in compliance with federal anti-fraud laws.

References

Centers for Disease Control and Prevention.
(n.d.). Health care fraud. Retrieved from https://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/healthcarefraud.html

Centers for Medicare & Medicaid Services. (2017). Medicare Learning Network (MLN) Fraud & Abuse Products. Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud-Abuse-Products.pdf

Jefferson University Hospitals. (2014, January 20). Preventing fraud, waste, and abuse and the Federal False Claims Act (Policy Number: 122.11). Retrieved from
http://hospitals.jefferson.edu/about-us/financial-statements-and-corporate-compliance/policy-122-11.html