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President George Bush proposed a two part strategy with initial implemented drug coverage to low-income beneficiaries coupled with a White House task force to develop a plan to reform Medicare (Health Policy, 2001). Under this plan beneficiaries with income 135% below the national poverty guidelines would be eligible for full prescription drug coverage and a sliding scale would be provided for those under 175% (Health Policy 2001).
The most controversial aspect of these proposals was whether or not Medicare should remain a public insurance that is managed by the federal government. Supporters felt that this program should continue existing programs in scope and nature while opponents claim that a program of this sort should exist in the private market. Proposals suggested that a national standard for drug benefits should be established with all beneficiaries being eligible for standard benefits and increased benefits being given to those who incur catastrophic expenses.…
Medicaid and Medicare Fraud
Describe health news story combating health care fraud Medicare Medicaid• Examine evaluate corporate structure governance, culture, focus social responsibility • ecommends
Medicare and Medicaid fraud: An overview
Medicare and Medicaid fraud: An overview
While there is still little consensus regarding the best ways to go about enacting healthcare reform, one issue that unites both Democrats and epublicans is the need to eliminate Medicaid and Medicare waste, fraud and abuse. According to a 2009 CBS News report: "One tiny pharmacy in a Hialeah [Florida] strip mall went from billing Medicare $13,000 in May to billing nearly a million dollars a month later," and regulators took no notice (osen & Bach 2009:1). It has been estimated by the Federal Bureau of Investigation (FBI) the fraudulent billings to public and private health care programs are 3 -- 10% of total health spending, $75 -- $250 billion per year on…
Iglehart, John K. (2010, July 22). The ACA's new weapons against health care fraud
New England Journal of Medicine, 363:304-30
Morris, Lewis. (2008, September). Combating fraud in healthcare: An essential component of any cost containment strategy. Health Affairs, 28 (5): 1351-1356.
Taitsman, Julie K. (2011, January 11). Educating physicians to prevent fraud, waste, and abuse.
Fraudulent activities such as these resulted in violations under the act, including a fine of not more than $25,000.00 or imprisonment for not more than five years, or both.
Analysis of Current Fraud legal analysis of the current fraud committed in the Medicare and Medicaid programs indicates that reforms are in place to detect this fraud, and the involvement of governmental, local and federal police and investigation authorities has increased as well. For example, the National Center Policy for Analysis (2001) reports that 350 FI agents are now investigating a record 2,300 potentially fraudulent cases in the medical industry. In addition, various government antifraud units are being allowed to tap into the Medicare trust fund for the first time to fund their budgets; $104 million for 2001 and more than $200 million for 2002. As a result of the high volume of Medicare and Medicaid fraud, in the past few…
Bennett, M. (2007). Criminal Prosecutions for Medicare and Medicaid Fraud. Retrieved April 4, 2007, at http://www.aapsonline.org/fraud/fraud.htm .
Antos, Joseph. (1997). The Magnitude of the Financial Crisis in Medicare. 1997
Subcommittee on Health Care, United States Senate.
National Center for Policy Analysis (2001). Fraud in Medicare. Retrieved April 4, 2007, at http://www.ncpa.org/health/pdh5.html .
Medicare and Medicaid Services (CMS), previously the Health Care Financing Administration (HCFA), that by the time 2011, health care expenditure will arrive at $2.8 trillion, as well as it will bill for 17% of the Gross Domestic Product. As a result, it is no revelation that white-collar offenders observe health care deception as a rewarding effort. Certainly, the General Accounting Office ("GAO") quotes that such deception accounts for up to 10% of entire health care expense (3).
As health care deception outlays taxpayers almost $100 billion a year, federal, as well as state agencies have given health care fraud tribunal a key center of attention. All through her term, Attorney General Janet Reno made impeaching health care fraud a top precedence at the Department of Justice ("DOJ"), subsequent only to brutal offenses (3).
The government focuses its pains to perceive, as well as take legal action against health care fraud…
(1) Adelaide Few & Jay Trezevant, Fighting the Battle Against Health Care Fraud & Federal Enforcement Actions, 72 FLA. B.J. 34, 34-6 (1998)
(2) Alice A. Love, Leniency Offered Health Care Providers that Admit Federal Fraud, S.D. Union Trib., Oct. 22, 1998
(3) Andy Bunds, The results of the Health Insurance Regulations on Health Care Fraud and Abuse, 72 Mont L. Rev. 63, 72 (2001)
(4) Brian A. Kaset, Sailing Without Safe Harbors: Physician Recruitment and the Law of Fraud and Abuse, 9 Healths Span. 9, 9 (1992)
Fraud and Abuse
United States v. Greber -- 3rd Circuit, 1985
Dr. Greber's company, Cardio-Med, supplied Holter monitors, a device worn by patients that records heartbeats for later interpretation. Investigations showed that Cardio-Med billed Medicare and gave a portion of each payment to the prescribing physician, under the heading, "interpretation fees," even when Dr. Greber actually did the interpretation of the data. It was found that the fixed percentage paid to the referring physicians was more than Medicare allowed for such services. Further, Medicare requires that the device be used eight hours or more to qualify for payment. Cardio-Med and Dr. Greber reported longer operation times than the patients actually used their monitors.
In 1977, Congress changed the fraud statute of Medicare to clarify such problems as "kickbacks." In the revised statute, kickbacks were defined as any remuneration that might in any way be perceived as encouraging one company…
Healthcare Law -- Ethics & Policy
Memo to ABC Hospital Board of Directors: How to develop strategies to help mitigate abuse and fraud within our organization by understanding fraud and abuse issues.
The Department of Health and Human Services has provided a great deal of good information for healthcare professionals and the public in terms of ways to avoid and/or deal with fraud and abuse. This document reflects the ways in which this hospital can be on the lookout for fraud and abuse when it comes to Medicare. This document will also explain the difference between fraud and abuse in the Medicare system.
Typically Medicare fraud means a person in this hospital -- or a doctor affiliated with this hospital contractually -- would knowingly submit false statements or somehow misrepresent what his or her services actually were, in an attempt to cheat the federal government. Also a healthcare…
Department of Health and Human Services / Centers for Medicare & Medicaid Services.
Medicare Fraud & Abuse. Retrieved March 1, 2015, from http://www.cms.gov .
American Hospital Association (AHA) might be interested in the pending legislation:
Although all three positions of the proposed bill would be of concern, two of the three would cause serious ramifications for the AHA and its members. The first would be the 5% annual reduction. This cut equates to a very serious amount of income for the industry especially if the cut was scheduled for across the board reductions. Hospitals and nursing homes are already working at bare bones and more cuts would cause serious financial dilemmas if implemented. If the cuts are unique to certain aspects of the Medicare billing system, the AHA would need clear details of where the proposed cuts would actually be coming from.
The second of the three major concerns would be the simplification for assessing penalties to providers accused of abusing the Medicare payment system. It is the AHA's stance that providers should still…
Miscoding on the Billing Forms Discussion Board
The fundamental basis for auditing Medicare and Medicaid billing is that the services provided are confidential, patient privacy must be protected, and the written word of the provider is the record of service provision upon which a review must be initiated (Harris, 2007). Auditing, however, must extend beyond the written record to establish that the services were actually provided to the patient or client and that the services were rendered according to the conditions described in the provider's written record (Harris, 2007)
As the practice manager, I would remind the physician that every employee has a duty to cooperate and a duty of loyalty to the employer. And I would explain that these duties obligate employees to comply with reasonable directions from their employers during an internal investigation. The employee should be party to a conversation that an internal investigation may or may…
Harris, D. (2007). Contemporary issues in healthcare law and ethics (3rd ed.). Chicago: AUPHA/HAP
Murphy, A.P. And Vandenberg, Q.H. (2003). How to conduct a fraud investigation. Retrieved from http://www.mhtl.com/pdf/How%20To%20Conduct%20A%20Fraud%20Investigation.pdf
U.S. Department of Health and Human Services and U.S. Department of Justice. Stop Medicare fraud. Retrieved from http://www.stopmedicarefraud.gov/aboutfraud/index.html
UP FOR DISCUSSION NOW: Can you think of a reason why Dr. Jones might over rule his wife (Yikes!!) if she tells him not to buy the machine (which is the conclusion of the sample solution, and what 1/4 of you determined in your own papers)? What might be some of the benefits of having the machine, even with it losing money? (Think about all the DaVinci robots being bought now by competing hospitals...)
ACA and EMS
The implementation of the Affordable Care Act (ACA) is sure to change the way EMS operate in the coming years. Accountable Care Organizations (ACO), for instance, are now responsible for overseeing how reimbursements are paid out to those agencies that provide health care -- and at the same time they are responsible for gauging whether or not quality care is delivered by providers (Koury et al., 2014). This is a tall order for a new functioning body and the ACOs tasked with these orders will have an indirect impact on how EMS operates. To see how that impact will be effected, an examination of the ACOs and hospitals interact requires examination -- because it is that interaction that will inevitably alter the way in which the EMS goes about their business. This paper will examine the relationship between the ACA, ACOs, hospitals and EMS and show how…
ACA. (2010). Sec. 1204, 124 STAT. U.S. Government Publishing Office. Retrieved from https://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf
Ahmed, A. et al. (2015). Not just an urban phenomenon: Uninsured rural trauma
patients at increased risk for mortality. Western Journal of Emergency Medicine, 16(5): 632-641.
Alpert, A. et al. (2013). Giving EMS flexibility in transporting low-acuity patients could
The facts that you have provided indicate extremely troubling circumstances that could seriously jeopardize the welfare of your organization. It is well-settled law that entities contracting for the services of subsidiaries are legally responsible for legal and ethical improprieties committed by those subsidiaries irrespective of whether or not the contracting organization had any specific involvement in or knowledge of those actions. Accordingly, we would strongly advise that you take immediate action to rectify the situations described in the manner outlined in our recommendations below.
To avoid the potentially serious criminal, civil, and financial consequences arising under MWHC's respondeat superior responsibility to prevent fraud and abuse in connection with its association with subsidiaries, it is hereby recommended that MWHC immediately:
1. Instruct the subsidiary to cease and desist from offering its contracted home health agency employees compensation of any kind in connection with client durable medical equipment (DME) orders from…
Reid, T. (2009). The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care. New York: Penguin Group.
USDHHS. (2004). U.S. Department of Health and Human Services-Office of Inspector
General-Statement of Organization, Functions -- and Delegations of Authority.
Federal Register. Vol. 69, No. 127; July 2, 2004. Retrieved November 14, 2010,
In the case of pill mills, participating physicians and pharmacists bill insurance companies or Medicare for prescription drugs, allowing participating beneficiaries to resell those drugs to criminal middlemen. The pharmacy then repurchases the drugs at a lower cost. According to the USGAO, any misuse of beneficiary identification information is a felony.
Criminals may also steal beneficiary information by creating drop boxes. The drop box scheme involves establishing a phony health care company in order to obtain insurance or Medicare payments. Like the drop box scheme, the pill mill scheme, and the rent-a-patient scheme, third-party billing also involves felony acts. Illegally obtaining beneficiary identification numbers, a criminal can use third-party billing agents to receive insurance payouts. The third-party billing company may not even be aware of the scheme. In other cases, the third-party billing company is a part of the scheme, defrauding by tacking on fraudulent claims to legitimate ones and…
Cornell University Law School. "Health Care Fraud." Retrieved Aug 7, 2008 from http://topics.law.cornell.edu/wex/healthcare_fraud
United States General Accounting Office (USGAO). "Health Care Fraud." Retrieved Aug 7, 2008 from http://188.8.131.52/search?q=cache:NcKXTYWPgDEJ:www.gao.gov/new.items/os00015t.pdf+health+care+fraud&hl=en&ct=clnk&cd=5&gl=us&client=firefox-a
Corporate fraud as a dishonest activity for organizations that is considered as white collar crime has serious legal implications. Though it can be difficult to detect and catch, it is important to prevent it by creating effective and efficient policies for the organizations that ensure an efficient system of checks and balances exists in the organization for its physical and fiscal security. Whenever fraud happens in a company or organization, it often takes the form of hiding sources of revenue, overstating expenses or growth, or disguising payments made to individuals in the company. Often, fraudulent activities within the organization are complex in nature and have a gross impact on the financial nature of the organization. It is usually perpetrated by the company management and other employees are often unaware of these fraudulent activities (Mele, 2005).
Corporate fraud, as difficult as it is to prevent, often has a ripple effect whereby…
Bertrand, V. (2009). Organizational Isomorphism and Corruption: An Empirical Research in Russia. Journal of Business Ethics, 89(1), 59-76.
Federal Bureau of Investigation. (2014). Rooting out health care fraud is central to the well-being of both our citizens and the overall economy. Retrieved April, 2014, from http://www.fbi.gov/about-us/investigate/white_collar/health-care-fraud
Mele, D. (2005). Ethical Education in Accounting: Integrating Rules, Values and Virtues. Journal of Business Ethics, 57(1), 97-109.
Panda, J.K. (2006). Accounting & Finance For Management. New Delhi: Sarup Book Publishers Pvt. Limited.
Identity theft and fraud of many types and forms are obviously a major inconvenience and hindrance to anyone that falls prey to a person that engages that crime. There are many variants and forms of fraud and identity theft out there. One of the more insidious and nasty examples of those crimes would be that which relates to healthcare. Indeed, to have people's wallet, healthcare and the taxpayer dollar on top of that all potentially compromised in one fail swoop is a very ominous and nefarious endeavor. Even so, it happens all of the time and to all sorts of people. egardless of the particular situation or scenario, any instances of fraud or abuse when it comes to healthcare insurance, healthcare providers and the services dispensed from all of the above are never a good thing. While healthcare is deemed to be a right to be extended without…
Badano, G. (2016). Still Special, Despite Everything: A Liberal Defense of the Value of Healthcare in the Face of the Social Determinants of Health. Social Theory &
Practice, 42(1), 183.
Budetti, P. P. (2015). New strategy, technology emerging in ongoing fight against healthcare
fraud. Modern Healthcare, 45(29), 25.
The Act creates a positive balance between government interests to save money and the interests of Medicare recipients to receive a wide range of drugs for their specific needs. The current ban on government negotiations with pharmaceutical companies serves to protect Medicate recipients by using the positives of the free market, such as the experience and purchasing power of PBMs. hile there are serious potential problems with this approach, such as the potential for fraud between pharmaceutical companies and private interests, overall the ban on government negotiations with pharmaceutical companies provides a good balance between recipient and government interests.
American Legislative Exchange Council. Prescription Drugs. 19 October 2005. http://www.alec.org/2/4/talking-points/7.html
Barry, Patricia. New Salvos in the Prescription Drug ars: Class action suits are exposing schemes that gouge consumers. AARP Bulletin, January 2005.
19 October 2005. http://www.aarp.org/bulletin/prescription/a2005-01-06-salvos.html
Dealey, Sam. Drug Dealings: Democrats had it right before. National Review Online, May…
American Legislative Exchange Council. Prescription Drugs. 19 October 2005. http://www.alec.org/2/4/talking-points/7.html
Barry, Patricia. New Salvos in the Prescription Drug Wars: Class action suits are exposing schemes that gouge consumers. AARP Bulletin, January 2005.
19 October 2005. http://www.aarp.org /bulletin/prescription/a2005-01-06-salvos.html
Dealey, Sam. Drug Dealings: Democrats had it right before. National Review Online, May 05, 2004, 9:12 A.M. 19 October 2005. http://www.nationalreview.com/comment/dealey200405050912.asp
healthcare issues country. How solve ongoing problem Medicare Fraud Abuse government sufficient effective regulation enforce. If, resolve problem? recommendation ? It Economics Healthcare economically sound.
Economics of healthcare
The population of the modern day society is faced with incremental pressures, but also incremental challenges, and these new issues impact all aspects of life, including the provision of healthcare services. For instance, the more and more technological developments made within the medical and pharmaceutical industries improve the quality of the medical services and as such the life expectancy of the patients. Then, the sustained academic research conducted also improves the quality of the services and the overall quality of the medical act.
In spite of the developments made, it must also be noted that the provision of healthcare services in the United States is a complex situation, with numerous ramifications and challenges. On a first note, it is revealed that the…
Angell, M.,2002, The forgotten domestic crisis, The New York Times, http://www.nytimes.com/2002/10/13/opinion/the-forgotten-domestic-crisis.html last accessed on August 8, 2011
Cunningham, W., 2003, The development of the U.S. health care system and its problems, UCLA Schools of Medicine / Public Health, http://www.ph.ucla.edu/hs/hs_100_4_02_lecture_cunningham.pdf last accessed on August 8, 2011
Garson, A., 2000, The U.S. healthcare system 2010, Current Perspectives, http://circ.ahajournals.org/content/101/16/2015.full last accessed on August 8, 2011
Gratzer, D., Why isn't government healthcare the answer? Free Market Cure, http://freemarketcure.com/whynotgovhc.php last accessed on August 8, 2011
Accounting and Audit Enforcement
1. The Sarbanes-Oxley Act applies to publicly-traded companies. Thus, it does not apply to non-profit entities. Nor does it apply to for-profit entities that are not publicly-traded. This is because SOX was passed specifically to address instances of accounting fraud in publicly traded companies that were undermining consumer trust in the capital markets (101.com, 2018). A publicly traded companies has a variety of different obligations under SOX that will help to reduce the opportunities and incentives for accounting fraud. Both opportunity and incentive are components of the fraud triangle – one needs to have a perceived need to commit the fraud and the circumstances with which to do so (ACFE, 2018).
Non-profit organizations have no obligations under SOX. However, there is a school of thought that holds that non-profit entities can benefit from some of the recommendations and mandates that SOX contains. Fritz (2016) writes that…
egistered nurses are both qualified, educated, and certified to provide a high quality of various care services that an individual may need in a home setting or elsewhere. Hence, providing these practitioners with the power to certify and provide home care is a solution to an overwhelming problem that has plagued the health care environment in recent years. Nursing practitioners, as a result of the nature of their work, are closely connected to the needs of individual patients. This means that they, more than many other health care providers and institutions, are able to assess the needs of individuals, their households, and the level of care they require. This places them in a position to accurately determine the need and/or of such individuals to obtain long-term home care and when such home care becomes unviable. As such, registered nurses who serve individuals in the home setting are able to maintain…
AARP Public Policy Institute. (2013). FAQs. Retrieved from: http://assets.aarp.org/rgcenter/ppi/ltc/ltss_faq.pdf
Brassard, A. (2011). Removing Barriers to Advanced Practice Registered Nurse Care: Home Health and Hospice Services. AARP Public Policy Institute. Retrieved from: http://www.aarp.org /content/dam/aarp/research/public_policy_institute/health/removing-barriers-advanced-practice-registered-nurse-home-health-hospice-insight-july-2012-AARP-ppi-health.pdf' target='_blank' REL='NOFOLLOW'>
health south accounting irregularities: A Presentation and Overview
As a part of this presentation, I, as an independent auditor commissioned by the committee of the firm representing the HealthSouth Corporation, wish to make clear that the company I have just audited, though tarred and feathered by the modern media, is not nearly at fault as one might initially believe, given the nature of the following components peculiar to the health services and health care industry. Although HealthSouth's supposed irregularities may have been elided in the public imagination with corporations such as Enron, it is not an 'imaginary corporation.' Mistakes were made, but these mistakes should not cause individuals to forget the ongoing quality of care still provided by the company.
The company's former CEO Richard M. Scrushy never told the company's primary accountants to falsify financial reports. Furthermore, these accountants would have reported accounting irregularities had they known about them.…
Brubaker, Bill. "HealthSouth employees say patients unshaken by scandal." The Washington Post. July 8, 2003. April 16, 2003. Washington Post.com. Web page accessed on July 28, 2002 at nbc13.com
Executives say they were not aware of accounting problems." MSNBC.com. April 13, 2003. Web page accessed on July 28, 2002 at nbc13.com
Johnson, Carrie. "HealthSouth to resist bankrupsy." The Washington Post. July 8, 2003. Washington Post.com. Web page accessed on July 28, 2002 at nbc13.com
ooderson has a strong case for arguing that the Ordinance passed by the County is unconstitutional. Article I Section 9 of the Constitution says "No Bill of Attainder ... shall be passed," and Article I Section 10 says "No State shall ... pass any Bill of Attainder." The fact that this Ordinance has been specifically designed to affect ooderson and only ooderson qualifies it as a Bill of Attainder, the term given to legislation that is designed to specifically affect a single individual. The Supreme Court ruling in Fletcher v. Peck (1810) holds "A bill of attainder may affect the life of an individual, or may confiscate his property, or may do both. In this form the power of the legislature over the lives and fortunes of individuals is expressly restrained." If ooderson can prove the religious motive of the Comissioner who designed the Ordinance, it violates the Establishment Clause;…
US Supreme Court. Fletcher v. Peck. 1810. http://caselaw.findlaw.com/us-supreme-court/10/87.html
Nevada Supreme Court. Scialabba v. Brandise Construction. http://law.justia.com/cases/nevada/supreme-court/1996/24632-1.html
The success of PPACA, and its provisions for people who are currently or chronically uninsured, will depend on reform of public programs as well as private insurance practices to create "new pathways to coverage (Gulley) and address the problematic link between employment and insurance coverage. In other words, employment should not be the only viable option for securing affordable insurance, nor should there be "significant work disincentives for people with disabilities" (Gulley). The law should help "reduce disparities in [healthcare] access (Gorin, 2010).
A number of provisions of PPACA have already taken effect. Beginning January 1, the law provided for a 50% discount on covered brand-name drugs. This provision was designed to close the coverage gap in Medicare Part D coverage, the so-called "Donut Hole." There is a 7% discount on generic drugs. The coverage gap will be completely eradicated by 2020, according to PPACA, making it even easier for…
Cobb, K., & Davis, C. (2007). The faces of the uninsured: One in four Texans has no medical coverage, posing dire physical risks for them and consequences for the state. Houston Chronicle 4/15/07.
Doheny, K. (1999). Filling a Health-Coverage Gap. WebMD. Retrieved from http://www.webmd.com/a-to-z-guides/features/filling-health-coverage-gap
Gorin, S.H., Gehlert, S.J., & Washington, T.A. (2010). Health care reform and health disparities: Implications for social workers. Health & Social Work 35(4), pp. 243-247.
Gulley, S.P., Rasch, E.K., Chan, L. (2011). Ongoing coverage for ongoing care: Access,
Organized crime presents certain unique challenges for law enforcement in the 21st century. As noted by Bjelopera & Finklea (2012) in their report to Congress on the history of organized criminal activity in the United States, modern organized criminal networks tend to be more fluid and less hierarchical than organized associations of the past. Organized crime networks are also more apt to outsource critical aspects of their operations, which can make building a unified case a challenge for law enforcement agencies (Bjelopera & Finklea, 2012, p.1). Diverting resources to combat terrorism have also left law enforcement agencies in the United States with fewer financial resources to combat other forms of organized crime, although some of the methods to trace both types of organizations, such as patterns of money laundering, are similar between both of these types of illicit associations.
Organized crime is defined as "criminal activity that, through violence or…
Bjelopera, J. & Finklea, K. (2012). Organized crime: An evolving challenge for U.S. law
Enforcement. CRS Report for Congress. Retrieved from: https://fas.org/sgp/crs/misc/R41547.pdf
Bradley, T. (2015).Cybercrime is the modern-day mafia. Forbes. Retrieved from:
Medical Coding Ethics
Ethical Concerns in Health Care Delivery: Focus on Medical Coding and Billing Practices
The objective of this study is to examine ethical concerns medical coding and billing in the physician office. Medical coding and billing has become very complex in light of health care reform. Recently, Christopher Gregory ayne, reported to be "dubbed the Rock Doc" was arrested on a dozen charges of Medicare fraud" when he was accused of fraudulently billing for "physical therapy procedures, such as massages and electrical stimulation, that were not necessary or in some instances had been provided at his prior medical practice in Miami." (eaver, 2013, p.1) It appears that where this doctor failed is billing for physical therapy when his staff was not properly accredited for providing these treatments.
Health Care Coding and Billing Changes
It was reported by Gunderman (2013) that October 1, 2014 is the deadline on implementing…
American Health Information Management Association Standards of Ethical Coding. (2008) AHIMA House of Delegates. "AHIMA Standards of Ethical Coding. Sept 2008. Retrieved from: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok2_001166.hcsp?dDocName=bok2_001166
Know your ethical obligations regarding coding and documentation (2009) Association of Clinical Documentation Improvement Specialists, August 4, 2009 HCPro. Retrieved from: http://www.hcpro.com/HOM-236942-5728/know-your-ethical-obligations-regarding-coding-and-documentation
Weaver, J. (2013) Miami Beach's 'Rock Doc' busted on Medicare fraud charges. The Miami Herald. Retrieved from: http://www.miamiherald.com/2013/09/30/3660611/miami-beachs-rock-doc-busted-on.html#storylink=cpy
Sufficient documentation a major hurdle for ICD-10 (2013) APCs Insider. Retrieved from: http://www.hcpro.com/HIM-297687-859/Sufficient-documentation-a-major-hurdle-for-ICD10.html
The ole legal nurse consultant may provide service in a number of roles, including but not limited to:
Trainer and in-service presenter
Quality improvement, risk management, claims management
Liability insurance marketer and clinical resource" (Chizek, 2003)
As standards of care constantly change, medical and nursing staff must keep informed of current standard to develop and/or modify policies and procedures, which must be maintained and secured indefinitely. In the event the facility is sued, these will be used to establish the current standard during the time of the questionable occurrence. Policies and procedures also provide the legal nurse consultant with the foundation for facility documentation to be judged for compliance. (Chizek, 2003)
The minimum length of time the modified policies and procedures should be kept is the time frame of the statute of limitations in the individual jurisdiction. In most jurisdictions,…
Brown, M.R. (1999, February). America's Most Wanted J-O-B-S. Black Enterprise, 29, 109.
Chizek, Mardy. "Can you use a legal nurse consultant? These specially trained and experienced nurses can be frontline protectors against liability suits. (Feature Article)." Nursing Homes, February 1, 2003.
Clark, Scott a.. "Keys on developing the best laid business plans," the Journal Record, April 12, 1999.
The program focuses on building an ethical culture, but does not appear to specifically address fraud risk assessments, controls over fraud prevention or other SOX provisions.
3) the company currently focuses on training and enculturation to sensitize its employees to ethical issues. One suggestion would be to align executive compensation with the objectives of the shareholders. Options only bring about temporary alignment, so shares or other long-term strategies should be used instead. This will help management to focus on both ethics and profitability. Another suggestion would be to build upon their existing program by creating job-specific training as well as corporate-wide training. This way the scenarios that the workers are exposed to are specific to situations they might see, which will bring the message closer to home.
No author. (2008) Sarbanes-Oxley. American Institute of Certified Public Accountants. Retrieved December 16, 2008 at http://thecaq.aicpa.org/Resources/Sarbanes+Oxley/
No author. (2008). Federal Sentencing…
No author. (2008) Sarbanes-Oxley. American Institute of Certified Public Accountants. Retrieved December 16, 2008 at http://thecaq.aicpa.org/Resources/Sarbanes+Oxley/
No author. (2008). Federal Sentencing Guidelines. Ethics Resource Center. Retrieved December 16, 2008 at http://www.ethics.org/erc-publications/federal-sentencing-guidelines.asp
eimbursement Ethics and Compliance: Impact of Health Care eform on Medical Coding and Billing
"Medical billing and coding lays the foundation for any successful healthcare provider," yet its common practices are undergoing significant changes under the recent proposal for health care reform (Griffey, 2013). The nature of medical coding and billing is increasingly becoming more and more complicated. The recent healthcare reform legislation, passed in 2010, promises to complicate the situation even further. Such reforms will undoubtedly have a huge impact on medical billing and coding processes.
The reform bill was a monumental piece of legislation passed by Pres. Obama and his Democratic supporters in 2010. There are a number of stipulations which aim to help increase access to appropriate health care for millions of Americans who are currently without any coverage, helping lower the cost of premiums too much more affordable rate for most Americans but also increasing the…
Eastaugh, Ben & Sternal-Johnson, Chris (2010). What will health care reform do to medical billing? MD Alliance Billing. Web. http://mdalliancebilling.wordpress.com/2010/03/22/what-will-health-care-reform-do-to-medical-billing/
Griffey, Kimberly. (2013). Medical billing and coding and health care reform: What you need to know. Ultimate Medical Academy. Web. http://info.ultimatemedical.edu/blog/bid/276367/Medical-Billing-and-Coding-and-Health-Care-Reform-What-you-Need-to-Know
Hart, Bradley. (2012). Ethics in Medical Coding: Theory and Practice. McGraw Hill.
Jackson, Jill & Nolen, John. (2010). Health Care Reform Bill summary: A look at what's in the bill. CBS News. Web. http://www.cbsnews.com/8301-503544_162-20000846-503544/health-care-reform-bill-summary-a-look-at-whats-in-the-bill/
Sociology Discussion Responses
Response to Post #
Your post raises some very important issues that face the entire nation as well as the individual states such as New Mexico. The largest social services programs such as Medicare and Medicaid are unsustainable for the long-term, largely because of the dramatic demographic changes in American society since their development. Today, the average longevity is almost double what it was in the early 20th century when the average life span was only 47 years of age. Likewise, the fact that the post-Word War II Baby-Boom generation is now entering retirement age means that larger than ever numbers of program beneficiaries will have to be supported by fewer working program contributors. Meanwhile, the economy is undergoing a very difficult period and unemployment and underemployment rates, even for college graduates, are at all time lows. Some of the most sensible approaches to solutions might include…
Integrity is a major issue for healthcare organizations because there are many avenues for fraud, and for people to demonstrate a lack of ethics. The problem is that the temptation is sometimes too great and despite the fact that there are laws in place to guard against these practices unethical behavior takes place anyway. The government, which supplies a lot of the money which goes for treatments through Medicare and Medicaid, has structured certain laws to make sure that the practices of healthcare organizations are ethical, but billions of dollars in fines are still doled out every year. The big drug companies complain of arcane and hard to decipher legalese, but the fact is that although they realize the issue and the penalty they continue to subvert the law. This paper looks at qui tam statutes and cases, Medicare and Medicaid admissions criteria, installing a corporate integrity program, and…
American Speech-Language-Hearing Association (ASLHA). (2010). Summary of self- referral and anti-kickback regulations. Retrieved from http://www.asha.org/practice/reimbursement/medicare/regulations_sum.htm
Hanford, J.T. (2001). Regulation of the healthcare professions. Ethics & Medicine, 17(3), 188-190.
Louthian Law Firm. (2012). Healthcare fraud qui tam whistleblower protection lawsuits.
Mattie, A. & Ben-Chitrit, R. (2009) The federal False Claims Act and qui tam actions: What every healthcare manager should know. Journal of Legal, Ethical and Regulatory Issues, 12(2), 49-65.
Through its partnership with the Department of Justice and the Human Health Services, the HEAT has expanded data sharing and improved information sharing procedures in order to get critical data and information into the hands of law enforcement agencies to enable them track patterns of fraud and abuse, and increase efficiency in investigating and prosecuting complex health care frauds (Department of Health and Human Services, HHS, 2011). The DOJ and the HHS have established cross government health care fraud data intelligence sharing work group that helps to improve awareness across the government on issues related to health fraud.
The Healthcare Fraud and Abuse Control Program (HFAC) is enshrined in the section 1128c of the social security Act. This Act authorized the Health and Human Services and works through the office of the inspector general and the department of justice to ensure that the control and designs towards control…
American Medical Association, (2013). Federal Fraud and Abuse Laws. Retrieved July 29, 2013
Department of Health and Human Services, HHS. (2009). The Department of Health and Human
and the Department of Justice Health Care Fraud and Abuse Control Program Annual
The problems facing Medicare recipients and the federal government almost seem to be overwhelming. There are proponents of a plan to privatize Social Security and health insurance, placing the onus on the individual to pay for his own health care through savings specifically for this. Some others would have the program go through the private HMOs who have, in the past, contained the costs of care by having primary care physicians manage a patient's care and purposely keeps the costs of care down.
As with Medicaid, the recipients of Medicare would have difficulty obtaining health care without this program. The recipients would most likely have no other health insurance. The trend being what it is, a lot of individuals retiring today are fortunate to have pensions from their companies, much less health benefits. ithout a national health insurance plan, like Medicare, those individuals would have to pay for health care…
Kay, Joseph. "Bush Plans renewed Assault on Medicaid." World Socialist Website. 8 Feb. 2005.
13 Aug. 2005. http://www.wsws.org/articles/2005/feb2005/medi-f08.shtml .
Kay, Joseph. "U.S.: States, Federal Government Prepare Massive Medicaid Cuts." World
Socialist Website. 11 May 2005. http://www.wsws.org/articles/2005/may2005/medi-m11.shtml .
The experiences of seniors within the healthcare delivery system will alter how all Americans view healthcare. The healthcare delivery systems and overall organizational structure in the United States has been slow to adjust but that rest of the world is currently in flux that will migrate into our system. Technological advances in communication have made telehealth and telemedicine vialbel solutions to our outdated healthcare industry orgainzational structre. While these types of advances are only in their infancy, "...there seemed to be broad acceptance that telehealth and telemedicine had provided positive benefits to the worlds healthcare delivery system." (Telehealth Applications) Our technoloically challenged seniors have actually discovered the trend within the healthcare system and telehealth and telemedicine seems to be an advance that will find worldwide support so we as a nation will be reqquired to jump on the bandwagon.
In conclusion, this article review focused on new Healthcare Delivery Systems…
Farnsworth, Chris. "The Truth About Fraud" Washington Monthly 01 May 1997.
Joshua-Amadi, Mabel. "Recommendations: A Study in Motivation: Recruitment and Retention in the NHS" Nursing Management. February (2003).
Soloye, Daniel J. "Privacy and Power: Computer Databases and Metaphors for Information Privacy" Stanford Law Review July (2001).
Telehealth Applications. (2004) "Current Telehealth Applications" Retrieved October 26, 2004, at http://www.startegis.com/epic/internet/inict-tic.nsf/PrintableE/it07545e.html
Stated to be barriers in the current environment and responsible for the reporting that is inadequate in relation to medical errors are:
Lack of a common understanding about errors among health care professionals
Physicians generally think of errors as individual that resulted from patient morbidity or mortality.
Physicians report errors in medical records that have in turn been ignored by researchers.
Interestingly errors in medication occur in almost 1 of every 5 doses provided to patients in hospitals. It was stated by Kaushal, et al., (2001) that "the rate of medication errors per 100 admission was 55 in pediatric inpatients. Using their figure, we estimated that the sensitivity of using a keyword search on explicit error reports to detect medication errors in inpatients is about 0.7%. They also reported the 37.4% of medication errors were caused by wrong dose or frequency, which is not far away from our result of…
Discussion Paper on Adverse Event and Error Reporting In Healthcare: Institute for Safe Medication Practices Jan 24, 2000
Patient Safety/Medical Errors Online at the Premiere Inc. page located at: http://www.premierinc.com/all/safety/resources/patient_safety/downloads/patient_safety_policy_position_2001.doc
Medstat / Shortell, S. Assessing the Impact of Continuous Quality Improvement on Clinical Practice: What It Will Take to Accelerate Progress.
Health Policy Monitor (2001) A Publication of the Council of State Governments Vol. 6, No. 1 Winter/Spring 2001 PO18-0101
American Healthcare System has been at the center of debate for many years. One of the most pressing issues confronting the healthcare system is Medicare and its beneficiaries. The purpose of this discussion is to focus on the ramifications of moving Medicare beneficiaries into managed care organizations (MCOs). Our investigation will illustrate that moving the Medicare beneficiaries into MCOs are a bad idea because there will not to be any real cost savings and many individuals are likely to be denied needed care.
An article found in American Economic Review explains that Medicare is the second largest government entitlement program in the United States. The cost associated with running this program is astronomical. The article asserts that in 1999 the government spent $230 billion or 13% of its budget on Medicare and its beneficiaries. (Antos and Bilheimer)
The major issue with Medicare is that it is expected to…
Angell, Marcia, and Arnold S. Relman. "Patents, Profits & American Medicine: Conflicts of Interest in the Testing & Marketing of New Drugs." Daedalus 131.2 (2002): 102+. http://www.questia.com/PM.qst?a=o&d=96539841
Antos, Joseph R., and Linda Bilheimer. "Medicare Reform: Obstacles and Options." American Economic Review 89.2 (1999): 217-221. http://www.questia.com/PM.qst?a=o&d=95229758
Fischer, Pamela P. "Parkinson's Disease and the U.S. Health Care System." Journal of Community Health Nursing 16.3 (1999): 191-204. http://www.questia.com/PM.qst?a=o&d=5001999538
Feldstein from Arizona. When the hospital was purchased by another company, they canceled the contract with Feldstein claiming that the actions that were taken were illegal. In the case, the court sided with Feldstein saying that a host of hospitals will use a variety of incentives to attract doctors. Under the Stark Law (which prohibits doctors and hospitals from making self referrals) they found that the health care facility did not violate any provision. (Stark Law 2010) However, the transaction was considered to be questionable, because of the unique arrangement that Feldstein and the hospital had about the referrals of patients. As a result, the decision would outline a number of different principals including: illegal activity arguments can be made by either party, recruiting arrangements based on referrals are in violation of federal law, hospitals need to carefully scrutinize recruiting agreements and they should develop strategies to protect themselves against…
Anti-Kickback Statute, 2011, Health Lawyers. Available from: [25 January 2011].
Federal Anti-Kick Back Laws and Safe Harbors, 1999, HHS. Available from:
Additionally, eston Smith's wife Susan Jones-Smith, was also a finance executive at the company, a further example of the incestuous relationships that characterized the financial leadership of HealthSouth. A failure of the company meant the failure in the financial future of the family of one's friends and spouses.
Another warning sign should have been the nature of the company's assets. The firm was able to conceal its financial shenanigans for so long from outside auditors because of its multiple and constant stream of acquisitions of a variety of inpatient and outpatient facilities. The nature of the acquisitions should have been a clear warning sign to be wary of HealthSouth's spiraling profits. The volume of transactions meant there was great difficulty in keeping track of the 'real' value of the different operations, despite the company's alleged revenues on paper.
Also, the existence of such superficial nods to ethical practices, such as…
Stuart, Alix Nyberg. (2005) "Keeping secrets: how five CFOs cooked the books at HealthSouth." CFO Magazine.
Safety net hospitals have traditionally provided medical services vital to public health. Unfortunately, the recent economic recession has dealt a hard blow to safety net hospitals, even to the point of forcing hospital closures. Fortunately, Health Care Reform has already positively impacted U.S. health care and will even revolutionize American health care in some respects.
The Effect of the Closure of Safety Net Hospitals on Public Health
Safety net hospitals, such as Grady Memorial Hospital, serve the public health through providing vital treatment of uninsured, underinsured, Medicaid, and Medicare patients, along with some privately insured patients (Dewan & Sack, 2008). In addition, some safety net hospitals are also teaching hospitals that train medical professionals who contribute considerably to public health. Unfortunately, economic pressures are forcing the closure of some safety net hospitals, resulting in the severe reduction of medical care in certain communities for the "poor and underserved" (Altman, Shactman,…
Altman, S.H., Shactman, D., & Efrat, E. (2006, Jan/Feb). Could U.S. hospitals go the way of U.S. airlines? Retrieved September 1, 2012 from Proquest.com Web site: http://search.proquest.com/docview/204650663/138ED25BFA63A547161/5?accountid=28844
Amalberti, R., Auroy, Y., Berwick, D., & Barach, P. (2005, May 3). Five system barriers to achieving ultrasafe health care. Retrieved September 1, 2012 from Proquest.com Web site: http://search.proquest.com/docview/222267835/138ED3FE9A36E21E74A/6?accountid=28844
Dewan, S., & Sack, K. (2008, January 8). A safety-net hospital falls into financial crisis. Retrieved September 1, 2012 from Nytimes.com Web site: http://www.nytimes.com/2008/01/08/us/08grady.html?pagewanted=1&_r=1
Felland, L.E., Cunningham, P.J., Cohen, G.R., November, E.A., & Quinn, B.C. (2010, January). The economic recession: Early impacts on health care safety net providers. Retrieved September 1, 2012 from Rwjf.org Web site: http://www.rwjf.org/files/research/55109.pdf
However, this might turn competent healthcare professionals away, who were angry that they no longer could exercise discretion over their treatment, in conference with their patients. Patients might refuse to come to the hospital. And those that did would cause costs to escalate, as they stayed longer, received more extensive care, and thus exhausted their insurance benefits.
A summary presentation of a comprehensive solution that would cover all of the issues
Firstly, the board of directors should be convened to establish a policy about what the religiously founded hospital considers to be a quality life and an ethical system of evaluating critical patients, when dispensing care. Doctors, nurses, and other involved personnel must be convened to discuss various issues that continually arise and a uniform policy must be established, so that such ethical decisions are not solely the burden of patients and healthcare providers in the field.
A press release…
National Coalition on Health Care. (2004) "Health Insurance Cost." Retrieved 2 June 2005 at http://www.nchc.org/facts/cost.shtml
National Coalition on Health Care. (2004) "Health Insurance Coverage." Retrieved 2 June 2005 at http://www.nchc.org/facts/coverage.shtml
The health care industry is heavily regulated and has several special risk areas that need to be looked out for. An effective compliance program is necessary in order to mitigate these risks. In addition to the challenges that are associated with taking care of patients, health care providers are subject to huge and sometimes intricate sets of rules that govern the coverage and reimbursement of medical services. Because federal and state sponsored health care programs play such a big role in paying for health care, compliance with these rules are necessary in order to avoid penalties that can occur. These penalties can include such things as recoupment of improper payments, along with sanctions imposed by Medicare and Medicaid against health care businesses that engage in abuse or fraudulent practices (Corporate esponsibility and Corporate Compliance: A esource for Health Care Boards of Directors, (n.d.).
A good health care administrator will…
Corporate Responsibility and Corporate Compliance: A Resource for Health Care Boards of Directors. (n.d.) Retrieved April 3, 2009, from Office of the Inspector General Web site:
Health Administration. (n.d.). Retrieved April 3, 2009, from Web site:
Content Find articles address financial reporting practices ethics standards health care finance, including * generally accepted accounting principles * corporate compliance, ethics, and fraud abuse
Financial management: Literature review
Healthcare institutions, like all organizations, are continually confronted with the four basic elements of financial management: deciding what to invest in or produce; how to finance those investments or products; how to manage assets, and how to report those assets in a manner that is useful and also complies with all necessary regulations. This paper will provide an overview of two recent articles, one on the necessity of uniform accounting procedures to ensure ethical and legal compliance amongst healthcare institutions and the other on the financial consequences of failing to do so for the institution itself.
Article 1: Maintaining the strength of your convictions
According to Larry Tyler's 2004 article "Maintaining the strength of your convictions" "Most financial executives…
Adam. (2007). Dot. Boston. Retrieved August 12, 2011 at http://adamp.com/college/us-gaap-vs.-international-gaap-vs.-unified-gaap/
Fong, Gary R., Randy Wiitala & Frederick Stodolak. (2011). Uncovering pharmacy department risks and opportunities. Healthcare Financial Management Association Journal. Retrieved August 12, 2011 at http://www.hfma.org/Publications/hfm-Magazine/Archives/2011/May/Uncovering-Pharmacy-Department-Risks-and-Opportunities/
Rode, Dan. (1990). Uniform accounting standards enable accurate comparisons.
Healthcare Financial Management. Retrieved August 12, 2011 at http://findarticles.com/p/articles/mi_m3257/is_n7_v44/ai_9174983/
Social, Cultural, And Political Influence in Healthcare Delivery
Social, cultural, and political inequalities are detrimental to the health and healthcare system of the U.S. This is because the U.S. is one of the most multicultural, overpopulated, diverse and undergoing rapid economic growth. The federal government has embarked on efforts geared at addressing unsustainable costs of health care in the U.S. With the leadership of the current president, Barrack Obama, initiatives of containing health care costs will evaluate and explore strategies to contain the growing costs of health care based on a system-wide while enhancing the value and quality of health care (Ubokudom, 2012). The apparent system of health care is rife with opportunities of minimizing waste, delivering coordinated, effective care, and improving well-being and health of all Americans. The government in collaboration with care providers must prioritize cost effective containment strategies with the greatest possibility for political success and non-partisan…
Albrecht, G.L., Fitzpatrick, R., & Scrimshaw, S. (2013). Handbook of social studies in health and medicine. London: Sage Publications.
Armstrong, E.G. (2011). The health care dilemma: A comparison of health care systems in three European countries and the U.S. Singapore: World Scientific.
Bale, J.R., Stoll, B.J., & Lucas, A.O. (2013). Improving birth outcomes: Meeting the challenge in the developing world. Washington, DC: National academies press.
Buseh, A.G. (2008). Empowering resilience: Improving health care delivery in war-impacted African countries: a case study of Liberia. Lanham, Md: University Press of America.
The Affordable Care Act works on the premise that all Americans should have access to health care insurance. Because this is provided through insurance companies, the system is only enforceable under certain conditions. One of the key tenets of health care reform is the idea that those with pre-existing conditions cannot be denied insurance coverage. This group of people has long had problems getting insurance, and insurance companies spend tens of millions to invent pre-existing conditions that would then be used to deny coverage. Even insurance commissioners have been known to take offensive and absurd stances on pre-existing conditions, arguing that insurance companies should not have to take customers with such conditions because the person is to blame for their pre-existing condition (Ferguson, 2013). With attitudes like this from people connected to the insurance industry, the only way that the Obama Administration was going to achieve universal health care…
Ferguson, D. (2013). Georgia insurance commissioner: It's your fault if you have a pre-existing commission. Raw Story Retrieved December 6, 2013 from http://www.rawstory.com/rs/2013/12/05/georgia-insurance-commissioner-its-your-fault-if-you-have-a-pre-existing-condition/
Klein, E. (2012). Unpopular mandate. The New Yorker. Retrieved December 6, 2013 from http://www.newyorker.com/reporting/2012/06/25/120625fa_fact_klein
Kliff, S. (2013). Washington State provides case study on effects of health care reform. Washington Post. Retrieved December 6, 2013 from http://articles.washingtonpost.com/2012-06-16/national/35461636_1_individual-mandate-health-insurance-insurance-reforms
AARP. (2013). For people 65+. American Association of Retired People. Retrieved December 6, 2013 from http://www.aarp.org /content/dam/aarp/health/healthcare_reform/2013-07/aca-factsheet-for-65-aarp.pdf' target='_blank' REL='NOFOLLOW'>
The stock was trading on pink sheets at $0.165 per share at the end of April 2003" (8).
As noted above, one of the key factors involved in what happened at HealthSouth was the enormous pressure to perform in the increasingly competitive for-profit healthcare industry, pressure that directly affected the decisions that were made concerning the types of accounting practices that were needed to "deliver the goods," at least on paper. Although absent from the foregoing list, Scrushy's name appears time and again in the investigation that followed. According to Jennings, "Like Enron, orldCom, and Tyco, HealthSouth placed tremendous pressure on employees to 'meet the numbers.' In April 1998, CEO Richard Scrushy told analysts that HealthSouth had matched or beat earnings estimates for 47 quarters in a row" (8). The role played by Scrushy in engineering the corporate culture that would allow these estimates to be reported with a straight…
Brickey, Kathleen F. 2006. "In Enron's Wake: Corporate Executives on Trial." Journal of Criminal Law and Criminology 96(2): 397-399.
Geyman, John P. The Corporate Transformation of Health Care: Can the Public Interest Still Be
Served? New York: Springer, 2004.
Jennings, Marianne M. 2004. "Incorporating Ethics and Professionalism into Accounting
Open-Source or Crowd-Source Initiatives
In accordance to the TED Talk, a crowd-source initiative is one that can be delineated as an enterprise attaining required services, conceptions, or content by beseeching and petitioning contributions from large crowds and sets of individuals, and particularly from the online community, instead of the conventional personnel or suppliers. In other words, crowdsourcing brings together the endeavors of several individuals taking initiative to bring resolve to small pieces that make up a larger puzzle. Crowdsourcing outlines the muscle that comes off in numbers (Noveck, 2015). The following segment will outline and discuss the manner in which a federal product, specifically Medicare and Social Security, can be transformed into a crowdsourcing initiative.
Some of the key products being provided or rendered by the Federal government include social security and Medicare. These particular products can be transformed into crowd-sourced initiatives. For starters, in recent periods, there have been…
Santosus, M. (2003). Why You Need a Project Management Office (PMO). CIO. Retrieved 10 February, 2016 from: http://www.cio.com/article/2441862/project-management/why-you-need-a-project-management-office -- pmo-.html
Noveck, B. (2015). Demand a More Open Source Government. Retrieved 10 February 2016 from: http://www.ted.com/talks/beth_noveck_demand_a_more_open_source_government
Affordable Care Act
What is the ACA?
The 2010 Affordable Care Act or the PPACA (Patient Protection and Affordable Care Act - H3590), nicknamed Obamacare, is the latest American healthcare reform legislation. The PPACA encompasses the Patient Protection Act, the Affordable Health Care for America Act, and portions of the Student Aid and Fiscal esponsibility Act and Health Care and Education econciliation Act, connected with health care. Additionally, it encompasses revisions to the Food, Drug and Cosmetics Act, Health and Public Services Act, and other legislations. Further regulations and rules have served to expand upon the ACA since its enactment in March 2010 (Affordable Care Act Summary). Summaries of the act have been updated as and when changes were effected.
The 2010 ACA represents an extensive, elaborate law which is designed to transform the U.S. healthcare system, through the provision of quality healthcare coverage within the means of nearly all…
"Affordable Care Act Summary." Obamacare Facts: An Independent Site for ACA Advice. Web. 14 Sep 2016. .
Fuscaldo, Donna. "ACA Changes: More Small Business Owners to Offer Coverage, Face Increased Compliance - Health Insurance - U.S. News." Health News Articles - U.S. News Health - U.S. News. 2016. Web. 15 Sep 2016. .
"Health Insurance Exchanges." Health Plans & Dental Coverage - Aetna. Web. 15 Sep 2016. .
Jost, Timothy and Harold Pollack. "Key Proposals to Strengthen the Affordable Care Act." The Century Foundation - Home.2015. Web. 15 Sep 2016. .
Ashley, Assistant Director, Criminal Investigative Division of the FI relates that in 1991: "...the U.S. Attorney's office in Los Angeles charged 13 defendants in a $1 billion false medical billing scheme that was headed by two Russian emigre brothers. On September 20, 1994, the alleged ringleader was sentenced to 21 years in prison for fraud, conspiracy, racketeering, and money laundering. He was also ordered to forfeit $50 million in assets, pay more than $41 million in restitution to government agencies and insurance companies victimized by the scheme." (2003) Ashley relates that the first Eurasian organized crime investigation of a significant nature involved a major underworld figure in the United States and specifically, Vyacheslav Ivankov who is a powerful Eurasian organized crime boss. Ashley states that Ivankov "...led an international criminal organization that operated in numerous cities in Europe, Canada, and the United States, chiefly New York, London, Toronto, Vienna, udapest,…
Albini, Joseph L. And R.E. Rogers. "Proposed Solutions to the Organized Crime Problem in Russia." Demokratizatsiya Winter 1998: p. 103.
Crime Without Punishment." (1999) the Economist August 28, 1999 the Makings of a Molotov Cocktail. The Economist 344, no. 8025.
Edward H. Sutherland (nd) Differential Association Theory. Online Criminology FSU.EDU available at http://www.criminology.fsu.edu/crimtheory/sutherland.html
Eurasian, Italian and Balkan Organized Crime (2003) Testimony of Grant D. Ashley, Assistant Director, Criminal Investigative Division, FBI Before the Subcommittee on European Affairs, Committee on Foreign Relations, United States Senate. 30 Oct. 2003. Federal Bureau of Investigations. Online available at http://www.fbi.gov/congress/congress03/ashley103003.htm
Beneficiaries of Three U.S. Social Programs
In the last two years, there has been a major reform of Medicare, Medicaid and other federal health care programs like the State Children's Health Insurance Program (SCHIP) under the general rubric of Obama Care. These programs are designed to cover the elderly over age 65 (in the future age 55), the poor who have no health insurance, and workers not yet covered by private health insurance or other federal programs. One of the main questions that must be addressed with Medicaid reform is whether the program should be nationalized like Medicare, even though such efforts will always provoke strong epublican opposition. One possible reform would be to expand Medicaid to universal coverage, which has already begun with the reforms of 2009-10. Medicaid is going to be partially opened to the general public, including those who have employer-based health insurance and incomes above the…
Cleverley, W.O., P.H. Song, and J.O. Cleverley (2010). Essentials of Health Care Finance, 7th Edition. Sudbury, MA: Jones & Bartlett Co.
Grugan, C.A. And C.M. Andrews (2010). "The Politics of Aging within Medicaid" in Hudson, R.B. (ed) The New Politics of Old Age Policy, 2nd Edition. Johns Hopkins University Press.
"Health Care Reform Will Expand Medicaid, Increasing Demands on Doctors" (2010). St. Petersburg Times, Politifact.com, February 25, 2010.
S.S. Hyde (2009). Cured! The Insider's Handbook for Health Care Reform. Hobnob Publishing.
My organization has a fairly high commitment to VBP, and I believe that with a plan it can become even more engaged with VBP over the course of the next three years. While one might naturally think that those who deliver medical services are the most important – they are very important – I would like to key in on the roles that the Finance, Purchasing and IT departments play in achieving the balance between high quality service delivery and cost control. By engaging all of the relevant stakeholders, and making VBP a central focus on the basis, with consistent messaging over the course of the three years, it is believed that we can set and achieve some fairly aggressive goals with respect to meeting VBP objectives.
All three of the departments will need to prepare by taking the time to review how the VBP program…
crime doesn't pay sometimes is a whole point which can't be applicable, especially when you're trusted with the management of multi-billion dollar corporation, and to be in charge of the well -- being of thousand of people. It's so difficult to criminalize someone's action, if such action doesn't cause any harm to anyone or if someone doing a lot of critical charity works. The case of Richard M. crushy can be described as one of the most important scenario which can acts as one of the success stories, showing how far most of these business ethnical values can be abused to hurt everyone for a period of time. As stated by Jennings (2012) in his book "Business Ethnics Class" unethical practices can only last for a short time, and nothing helpful can be found out of it.
However, the carpenter teachings regarding people who do not pursue wisdom that are…
Sense of entitlement
Jennings (2004a) identified that many corporate cultures are less concerned about their fraud because of their philanthropic endeavors. These good works seem to blind them to their culpability and cause them to both "overestimate their ability and underestimate the risk of being found out" (p. 17). This sense of entitlement constitutes two of the factors that Jennings identifies as "Wild West behaviors" (p. 13) that are common to organizations that ethically collapse; A "culture of innovation like no other" and a "culture of social responsibility" (p. 17). She notes that "the attitude develops slowly as the other factors of iconic status and high levels of success consume the individual right up to a feeling of invincibility" (p. 17). This is amply demonstrated in the behavior of Richard Scrushy, who despite all of the evidence arrayed against him continues to proclaim his innocence of any wrong doing.
Jennings (2004b) identified common red flags that would point to corporate counsel that an investigation into the accounting of the firm might be in order. She indicated that in HealthSouth's case legal counsel "fits the inaction mold" (p. 45), and "like executives at WorldCom, Enron, and Tyco, executives at HealthSouth, particularly Scrushy, lived lavish lives" (p. 46). She concludes that "the presence of many elaborate perks is a red flag all can see" (p. 46). It is these perks that, according to Neeley & Boyd (2010) "encourage[s] executives to take excessive risk with other people's money" (p. 548).
It is also wise to have it reviewed by a doctor or attorney, the Family Doctor eb site suggests; that way you can be assured that what you wish to have done with you and to you if you become incapacitated is "understood exactly as you intended" (Family Doctor).
The advance directives are sensitive and private, and they are very important for seniors. But the advance directives can be controversial, so it is wise for older people to know the law and understand the facts. To wit, there have been rumors and falsehoods spread on the orld ide eb and elsewhere about the advance directives that are spelled out in the recent overhaul of the healthcare system. Former governor of Alaska Sarah Palin made news in the summer of 2009 by asserting that the advance directives in the healthcare overhaul created a "death panel" of bureaucrats who will "decide, based…
Binstock, Robert H., and George, Linda K. (2010). Handbook of Aging and the Social
Sciences. Maryland Heights, MO: Academic Press.
Black, Jane A. (2008). Notes: The Not-So-Golden Years: Power of Attorney, Elder Abuse, and Why Our Laws are Failing a Vulnerable Population. St. John's Law Review, 82(1), 289-314
Collier, Elizabeth. (2005). Latent age discrimination in mental health care. Mental Health
Marketing in the biotechnology industry is critically important. The basic path to market involves receiving regulatory approval for products. From there, marketing is conducted to physicians directly, necessitating a relatively large sales force. The presence of competing treatments necessitates significant investment marketing, compounded by the impact of the need to recoup the sunk costs associated with product development. In addition, marketing in the biotechnology industry is strictly regulated by the Food and Drug Administration. The FDA exerts tight control over marketing -- a firm is only allowed to promote products for approved uses. Off-label marketing -- defined as marketing a product for uses not approved by the FDA -- is prohibited and firms found guilty can be subject to significant fines.
An example, of the strong regulatory influence on marketing can be found in the approval that United received in July for Tyvaso. The product, already delayed multiple…
MSN Moneycentral: UTHR. (2009). Retrieved October 29, 2009 from http://moneycentral.msn.com/companyreport?Symbol=U.S.%3aUTHR
2008 United Therapeutics Annual Report (includes Form 10-K).
United Therapeutics website, various pages. (2009). Retrieved October 29, 2009 from http://www.unither.com/
Press Release: United Therapeutics. (2009). FDA approves Tyvaso (treprostinil) inhalation solution for the treatment of pulmonary arterial hypertension. Retrieved October 29, 2009 from http://ir.unither.com/releasedetail.cfm?ReleaseID=400062
Blue Cross Blue shield is an association of 42 independent, locally operated health plans. As such, each health plan in the organization is a private insurer that offers coverage to mostly corporate employees. Collectively, they cover 81.5 million people in the U.S. And Canada, and Represent 28.6% of the U.S. population. Through membership in the association, the independent insurers (which formulate their own strategies) are able to offer health plans that can be taken to other areas of the country by pooling the medical professionals that they do business with. In addition to private companies, Blue Cross Blue Shield has partnered with the U.S. Government to offer Medicare services. In 1939 the Blue Cross symbol was officially adopted by a commission of the American Hospital Association (AHA) as the national emblem for plans that met certain guidelines. Blue Cross and Blue Shield insurance companies were set up as community sponsored,…
Assessing the ability of these individuals to perform basic tasks in their daily lives can also have much significance (Marshall, Warren, Hand, Xie, & Stumbo, 2002). Many older Americans are able to feed and clothe themselves without apparent problems, but others are not as fortunate (Marshall, Warren, Hand, Xie, & Stumbo, 2002). If they are unable to do these things correctly without help, their nutritional status will often suffer (Marshall, Warren, Hand, Xie, & Stumbo, 2002). Patients who are older should be assessed for their ability to do these simple tasks, and also for their ability to perform slightly more complex tasks such as fixing their own meals, cleaning their house, and balancing their checkbook (Marshall, Warren, Hand, Xie, & Stumbo, 2002). Sometimes cognitive impairment will lead to a lack of nutrition, and when this is the case, it often shows up in forgetfulness and an inability to perform even…
Bartholomew LK, Parcel GS, Kok G, & Gottlieb NH. 2001. Intervention Mapping: Designing Theory and Evidence-Based Health Promotion Programs. Mountain View, CA: Mayfield Publishing Company.
Collinsworth, R., & Boyle, K. 1989. Nutritional assessment in the elderly. Journal of Gerontological Nursing 15(12): 17-21.
Gambrell, K.A. 2003. White House rolls out Medicare reform plan. United Press International.
Industry Group 91, 2000. President Clinton releases new state-by-state report demonstrating urgent need for Medicare reform. Regulatory Intelligence Data.
Fault: An Alternative to the Current Tort-Based System in England and Wales
The United Kingdom
statistics regarding claims
THE NATIONAL HEALTH SYSTEM
OBSTACLES TO DUE PROCESS
THE CASE FOR REFORM
THE REGULATORY ENVIRONMENT
THE RISING COST OF LITIGATION
LORD WOOLF'S REFORMS
MORE COST CONTROLS
THE UNITED STATES
THE INSURANCE INDUSTRY
TORT REFORM IN AMERICA
STATISTICS FOR ERROR, INJURY AND DEATH
THE CALL FOR REFORM IN 2003: A FAMILIAR REFRAIN
THE UNITED STATES SITUATION, IN SUMMARY
NEW ZEALAND CASE STUDIES
THE SWEDISH SCHEME
COMPARISON: WHICH SYSTEM IS BETTER?
FIRST: UNDERLYING DIFFERENCES
TALKING TORT: AMERICAN PECULIARITIES
AMERICANS CONSIDER NO-FAULT
BRITAIN CONSIDERS NO-FAULT
Appendix A THE UNITED KINGDOM
At issue is the economic effectiveness of tort law in the common law legal system of England and Wales, as applied to medical and clinical negligence and malpractice cases. In response to economic concerns and a continual…
Once the written request is received, we will pay within 30 days (PCC.com, no date). If you paid by credit card, we will issue the refund to your card directly. If you paid cash, we will issue you a check.
This policy is ideal for a small generalist office.
The policy should outline the Medical Associates position clearly, so that the patient has an understanding of how billing and collections work from our end. This is important because of medical offices are somewhat unique in this regard compared to other businesses. The multiple means of payment, often for a single bill, necessitate this written explanation for the patient.
The main objective of the financial policy is to effectively communicate the means and methods of payment to the patients. Not only should it clarify the role of the office, but it should also clarify for the patient their role…
Valerius, Bayes, Newby & Seggern. (2008) Medical Insurance: An Integrated Claims Process Approach. McGraw-Hill, New York, 2008.
Website: MedicalCodingandBilling.com. Various pages. Retrieved February 20, 2009 at http://www.medicalcodingandbilling.com/pract_management.htm
No author. (no date). Writing a Financial Policy. Physician's Computer Company. Retrieved February 20, 2009 at http://www.pcc.com/practmgmt/business/finpol.php
No author. (no date). Financial Policy. Napa Valley Orthopaedic. Retrieved February 20, 2009 at http://napavalleyortho.com/financial_policy.html
The statute applies even where there is no actual government reimbursement.
The opportunity to invest in a "private-pay only" joint venture may, in some circumstances, constitute an inducement to physicians to refer patients to the joint venture partner for other services covered by governmental programs.
In general, violation of the statute is a two-way street
While it is theoretically possible for one person to violate the statute by offering a kickback to (or soliciting a kickback from) another person even where the other person refuses to play ball, one does not commonly see prosecutions based on that fact situation.
Where the requisite bad intent exists, an arrangement may violate the statute even where there are also legitimate purposes behind the arrangement.
Many claimed Anti-Kickback Statute violations arise from arrangements that may serve legitimate, socially useful purposes, such as providing healthcare services that might not otherwise be available in the local…
Black's law dictionary. (1990). St. Paul, MN: West Publishing Co.
Davis, A. (2011, May 26). Anti-kickback statute. American Health Lawyers Association.
Retrieved from http://www.healthlawyers.org/ hlresources/Health%20Law%20Wiki/Anti-Kickback%20Statute.aspx' target='_blank' REL='NOFOLLOW'>
Prospective Payment System and how that system has impacted the nursing home industry. The writer explores how the system operates and explains its necessary elements. The writer than discusses the impact and significant elements that the system has on the nursing home industry. There were 10 sources used to complete this paper.
One of the most pressing concerns facing the nation today is the health care system. The medical community allows people to live longer than ever before, which means there is an increased need for nursing home facilities to accommodate the additional members of senior society. In addition to a longer life those who are entering nursing homes must deal with the need to pay for such care.
The Prospective Payment System has been used to offset the cost of care and to alleviate the complications faced by those who enter the nursing homes as well as their family…
Early Effects of the Prospective Payment System on Access to Skilled Nursing FacilitiesNursing Home Administrators' Perspective
Disease management over the Internet reduceshospitalization.
Health Care Strategic Management; 3/1/2001
chief economic principle that must be confronted in the horrifying picture Steven Brill paints in "Bitter Pill: Why Medical Bills Are Killing Us" is the devastating effect caused by economic monopoly. Brill tiptoes around the issue, and basically defines monopoly by the concept of "powerless buyers" -- -but the economic conditions that render buyers powerless are economic conditions that restrict a buyer's freedom of choice, which is precisely the problem with American medicine in Brill's article. Doctors -- or by extension the Medical Industry -- represent a monopoly. There may be a plethora of pharmeceutical companies that exist, and which ostensibly compete under heavily regulated industries (which include a close government supervision on potentially monopolistic new inventions, such that copyrights and patents in pharmaceuticals are guarded under law for a mere fraction of the time that the copyrights and patents, for example, involved with Walt Disney's trademark cartoon character Mickey…
Care Technology and Ethical Concerns
Complete APA eference
Fed'n of State Med. (2014, April 26). State Medical Board's Appropriate egulation of Telemedicine (SMAT) Workgroup, Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine. etrieved from www.fsmb.org/pdf/FSMB_Telemedicine_Policy.pdf
Briefly description of the project
Under telemedicine, one gets multiple practice spheres for healthcare lawyers, including reimbursement, payment, abuse and fraud, privileging and credentialing, privacy, peer view, licensing, as well as regulatory compliance. There is need for healthcare proponents have got to comprehend telemedicine as well as its complex framework in order to serve the growing area better. Advancement in technology, expanding healthcare accessibility within the framework of the "Affordable Care Act," emphasizing on affordable quality of care, as well as the propagation of movable medical tools have placed telemedicine at the frontline of healthcare delivery. Since it began over 5 decades ago, range of telemedicine has broadened and…
Fed'n of State Med. (2014, April 26). State Medical Board's Appropriate Regulation of Telemedicine (SMART) Workgroup, Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine. Retrieved from www.fsmb.org/pdf/FSMB_Telemedicine_Policy.pdf
Kadzielski, M. A., & Kim, J.-Y. (2014, July 29). Telemedicine: Many Opportunities, Many Legal Issues, Many Risks. Retrieved from Pepper Hamilton: http://www.pepperlaw.com/publications/telemedicine-many-opportunities-many-legal-issues-many-risks-2014-07-29/
Welcome fellow nurses and other medical professionals or advocates. Like me, you are surely aware of the vastly and quickly changing climate in the medical community when it comes to things like continuum of care, accountable care organizations, medical homes and nurse-managed health clinics. I will speak about all of these things and what the future would seem to hold for each of them.
When it comes to the overall continuum of care, the Affordable Care Act was certainly a game-changer and will greatly shape the future of the United States medical system. There has been a swelling in the efforts by many healthcare providers to manage what is often called the "continuum of care" for patients. The doctors and health systems that exist out there are being formed and shaped into a number of different structures and agreements with the aim to achieve essentially one basic thing….to manage the…
AEI. (2013). Sure, Obama's 'cash for clunkers' stimulus cost $1.4 million a job - but, you know, cars - AEI. AEI. Retrieved 19 June 2015, from http://www.aei.org/publication/sure-obamas-cash-for-clunkers-stimulus-cost-1-4-
Budryk, Z. (2015). Special report: The future of accountable care organizations.
FierceHealthcare. Retrieved 19 June 2015, from http://www.fiercehealthcare.com/special-reports/special-report-future-accountable-care-organizations
(Mechanic, 2006, p. 11) (Sparrow, 2000, p. 9) Lastly, low reimbursement may be a the center of concerns about cost shifting to private insured persons, private insurance reimbursement contracts and those with the least bargaining power private pay patients, though there is good evidence that this is limited in rural provider offices and institutions as compared to those in urban settings. (Kula, 2004, p. 490) This phenomena known as cost shifting effects both urban and rural settings, on an economy of scale, as well as by the sheer fact that rural communities are then afforded more limited care. (Kula, 2004, p. 490)
In closing low reimbursement of available care in rural areas negatively affects both availability of care to those living their as well as quality of care, the ability of the community to recruit better service providers and the nation in the sense that even the urban areas are…
Havighurst, C.C., & Richman, B.D. (2006). Distributive Injustice(s) in American Health Care. Law and Contemporary Problems, 69(4), 7.
Kula, M.C. (2004). U.S. States, the Medicaid Program and Tax Smoothing. Southern Economic Journal, 70(3), 490.
Mechanic, D. (2006). The Truth about Health Care: Why Reform Is Not Working in America. New Brunswick, NJ: Rutgers University Press.
Romzek, B.S., & Johnston, J.M. (2002). Effective Contract Implementation and Management: A Preliminary Model. Journal of Public Administration Research and Theory, 12(3), 423.
Access, Cost, and Quality of the Massachusetts State Health Program: A Model for the Nation?
Few issues are as controversial or as pressing in terms of national policy than healthcare, which was and continues to be a prominent election issue and matter of public debate and scrutiny. Technological and pharmaceutical advancements and innovation have created a wealth of opportunities for improved quality of life and quality of care for many nations and individuals, but paying for this care -- and determining how much care should be paid for -- remains a complex and divisive issue throughout the developed world. Innovation is not cheap and neither is the use of many newer medical technologies, and aging populations that require greater levels and longer periods of care are also placing a strain on many healthcare systems.
The United States is one of the only developed nations that lacks an implemented…
Chen, C., Scheffler, G. & Chandra, A. (2011). Massachusetts' Health Care Reform and Emergency Department Utilization. New England Journal of Medicine 365: e25.
Gabel, J., Whitmore, H. & Pickreign, J. (2008). Report From Massachusetts: Employers Largely Support Health Care Reform, And Few Signs Of Crowd-Out Appear. Health Affairs 27(1): 13-23.
Heslop. K. (2010). How does U.S. healthcare compare to the rest of the world? Guardian. Accessed 15 October 2011. http://www.guardian.co.uk/news/datablog/2010/mar/22/us-healthcare-bill-rest-of-world-obama
Maxwell, J., Cortes, D., Schneider, K., Graves, A. & Rosman, B. (2011). Massachusetts' Health Care Reform Increased Access To Care For Hispanics, But Disparities Remain. Health Affairs 30(8): 1451-60.