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HS410 Unit 8 Assignment

HS410 Unit 8 Assignment

Sample Answer 

HS410 Unit 8 Assignment

Introduction

The American Healthcare system faces the challenge of devising a strategy of achieving simultaneously three key objectives, namely excellence or high quality in standards of giving care, equity or balance in accessing quality care, and a level of cost control when providing quality care to all persons (Bodenheimer, 2008). Currently, cost concerns have overshadowed excellence and equity considerations as the dominating health policy themes. Business coalitions have also overshadowed consumers as the main articulator of the needed change in healthcare. Drummond et al. (2015) assert that there is a rapid acceptance of the idea that healthcare is more of an economical product than it is a social good and a quality and access philosophy defined in adequate or minimal as opposed to optimal levels. In the case scenario, the care facility is struggling to remain solvent. The healthcare facility hires a consultant to rectify the financial problem, and the consultant suggests that the Medicaid reimbursement statements can be adjusted to reflect high amounts that could benefit the healthcare facility.

Ethical Challenges

The finance manager is faced with the challenge of keeping the healthcare facility solvent without defrauding Medicaid. The consultant offers a solution that seems to be applicable yet is against the law. If he reports the consultant to the Center for Medicare and Medicaid Service (CMS), the facility will be at risk of not receiving reimbursement, resulting in its closure. The closure of the facility will render the finance manager jobless and the title of ‘whistleblower’, which can be a barrier to successfully obtaining another job in the future. Secondly, the finance manager can report the consultant to the facility administrator, but the latter was a college mate of the consultant. Hence, reporting the consultant would be a case of one person’s word against another. The facility owner may choose to side with his college mate and dismiss the finance manager’s accusations. The accusations could also work against the finance manager, and he could possibly find himself summoned in a defamation lawsuit filed against him by the consultant.

Possible Options to Consider

Fraud refers to the act, omission, expression, or concealment of which the intent is constructive or actual, calculated to as deception to others to their disadvantage (Thebarge, 2009). Fraud in Medicaid reimbursement occurs when a provider intentionally attempts to defraud the government or when an insurer commits a crime such as service billing that was not provided or through falsification of documents or claims that may increase the cost to the insurer or government (Center for Medicare and Medicaid Services, CMS, 2017). Abuse, on the other hand, refers to the tendency of a professional to deceive, which can lead to actual fraud. According to the CMS (2017), abuse can be illustrated as misusing codes when making a claim, such as unbundling or upcoding codes, excessive charging of supplies or services, or billing unnecessary medical services. With these in mind, the finance manager can consider either reporting the matter to the facility manager or making a direct report to the CMS. The first option, as discussed earlier, can have a negative outcome. The second option is the most viable one.

Chosen Course of Action

The federal laws that govern Medicare and Medicaid abuse and fraud include the United States Criminal Code, Social Security Act, Physician Self-Referral Law (Stark Law), Anti-Kickback Statute (AKS), and False Claims Act (FCA) (CMS, 2017). These laws give specific administrative, civil, and criminal remedies that the government may impose on entities or individuals found culpable of committing abuse and fraud in the Medicaid and Medicare program. Violation of these laws can result in Civil Monetary Penalties (CMP), non-payment of claims, civil and criminal liability, and exclusion from all the health programs offered by the Federal government (CMS, 2017).

The finance manager can submit the complaint anonymously to the Office of Inspector General in charge of protecting the Medicare and Medicaid integrity under the Department of Health and Human Services (HHS) program (CMS, 2017). The OIG is authorized to exclude from Medicare and Medicaid entities and individuals who engage in fraud or abuse and impose CMPs for specific violations. In order to avoid any backlash, the finance manager has the option of reporting the abuse and fraud to the OIG anonymously. By reporting anonymously, no information that is traceable to the complaint will be made to the finance manager.

Probable Result of the Course of Action

According to CMS (2017), the Federal False Claim Act (FCA) protects against overcharging the government or selling sub-standard services or goods to it. The FCA imposes civil liability on a person or entity that knowingly causes or submits a fraudulent or false claim to the federal government. The civil penalties for FCA violation may include penalties of up to $21,916 as well as three times the amount that the government incurs in costs due to false claims. Additionally, an FCA criminal statute exists that can impose to entities or individuals that submit falsified information an imprisonment sentence, penalties, or both.

Conclusion

Attempting to defraud the Medicaid and Medicare programs is a criminal offense. A person or entity that is found culpable of fraud or abuse of the programs faces possible charges, imprisonment, penalties, and fines. The finance manager will be in a better position if he reports the incident to the OIG, albeit anonymously. By so doing, he will protect his career and also distance himself from any individual charges of fraud and abuse that may be placed against him by the CMS.

References

Bodenheimer, T. (2008). Coordinating care—a perilous journey through the health care system.

Center for Medicare and Medicaid Services (2017). Medicare Fraud and Abuse: Prevention, Detection, and Reporting. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud_and_Abuse.pdf

Drummond, M. F., Sculpher, M. J., Claxton, K., Stoddart, G. L., & Torrance, G. W. (2015). Methods for the economic evaluation of health care programmes. Oxford university press.

Thebarge, L. W. (2009). An Analytical Summary of:’A Gathering Storm: The New False Claims Act Amendments and Their Impact on Healthcare Fraud Enforcement’by Messrs. R. Rhoad, Esq. And M. Fornataro, Esq. R. Rhoad, Esq. And M. Fornataro, Esq.(September 30, 2009). The Health Lawyer21(6).

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Question 


HS410 Unit 8 Assignment

Assignment Details

Unit outcomes addressed in this Assignment:

HS410 Unit 8 Assignment

HS410 Unit 8 Assignment

  • Identify personal ethics.
  • Understand professional codes of ethics.
  • Ensure personal and professional codes of ethics are in synch with organizational ethics.

Course outcomes addressed in this Assignment:

HS410-5: Integrate personal and professional ethics to achieve organizational goals.

Instructions:

You are the finance manager in a long term care facility that is struggling to remain solvent. The facility’s administrator has hired a consultant to work with you to increase Medicaid reimbursement. The consultant recommends that you be more “liberal” in coding the severity of residents’ needs to justify greater reimbursement. The consultant tells you, “everybody does it” and, “it’s an undetectable way to boost revenue”.

You believe this approach is somewhere between inappropriate and illegal. You know the consultant is being paid on a commission and is an old college buddy of the facility administrator. You also recognize that your facility could soon go out of business and leave you without a job.

In a two page paper, respond to the following:

What are your ethical challenges?

What are your options?

What is your chosen course of action?

What will probably happen as a result of this course of action?

Requirements:

  • 2-3 pages in length (not including cover and reference pages)
  • A minimum of three outside resources (one of these resources can be your textbook)
  • Your paper should be formatted according to APA, include a proper introduction, appropriate headings, and conclusion.

Submitting your work:

Submit your Assignment to the appropriate Dropbox.

To view your graded work, come back to the Dropbox or go to the Gradebook after your instructor has evaluated it. Make sure that you save a copy of your submitted work.

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