Abuse refers to practices or incidents that are not consistent with sound and accepted medical healthcare business or economic practices, whereas fraud is the intentional misrepresentation or deception of services that a person knows not to be true and could lead to an unapproved repayment to a practice (Buchbinder & Shanks, 2011).
The main difference between abuse and fraud comes down to the individuals intention and aims. However, both the two practices have a similar impact. They waste valuable assets and supplies from the trust fund of the Medicare that would be otherwise be utilized to offer care to beneficiaries of Medicare. Therefore, for a situation to be adjudged fraudulent the intention is vital.
In situations where commission of fraud has occurred, the government has the ability to seek criminal convictions in the federals, suspend the alleged provider of the healthcare program, taking actions of an administrative nature to withdraw the parties that are responsible from the healthcare program (Buchbinder & Shanks, 2011). On top of that economic sanctions can be imposed at the will of the sector of Human and Health Services secretary.
In specific, abuse is regarded as a minor offence in comparison to fraud. Abuse generally occurs when activities that are not in tandem with billing guidelines and proper coding are practiced. Once abuse has been established to have occurred, the state normally recovers expenses made paid by mistake and more often suspends the provider of the healthcare that is considered abusive. Additionally, civil economic sanctions can be levied.
Examples of Abuse include; billing services at different rates to distinct customers, overuse of healthcare and medical services (e.g. making schedules for patients for numerous visits to acquire more economic gain.) and questionable billing practices and patterns, that may lead to needless reimbursement from the carrier. Examples of fraud include altering medical records or giving false health necessity for a procedure to validate payments. Another case of fraud is where the healthcare practitioner bills for services that have not been given and also a physician asking for novel patients by providing waived co- payments. Lastly, fraud can also be represented in form of misrepresentation of description of furnished services, dates or the personality of the beneficiary.
Steps to Ensure Compliance Is Legal and Effective
As a compliance manager, I will insist in providing education on security and privacy guidelines, software technologies, data management and education on patients. Specifically, I will encourage persistent education on novel laws and regulations pertaining to abuse and fraud. The healthcare organization under my watch has to offer standardized refresher education on privacy, compliance and security to all the members (Buchbinder & Shanks, 2011).
Another measure would be to proficiency on the utilization of statistical algorithms and use of Computer Assisted Coding. Abuse and fraud is most likely to take place over a long period of time, therefore CAC software is utilized to develop a better accurate and thorough audit trails which will advance post-payment and pre-payment audits to recognize fraudulent practices over time and coding errors.
Alternatively th health organization can increase the number of trainees to take the lead in review of medical records and creation of algorithm to detect financial abuse and fraud and coding (Buchbinder & Shanks, 2011). I will encourage the health organization to fund research programs within, to update screening tools that can be used in general standard and that are more sensitive in recognizing patterns of abuse and fraud in a pre-emptive way.
Buchbinder, S., & Shanks, N. (2011). Introduction to health care management. New York: Jones & Bartlett Publishers .
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