Fraud and Abuse in Healthcare

Fraud is rampant in the healthcare industry. The size, scope, and complexity of the healthcare industry can attract individuals and organizations intending to defraud third-party payers, government agencies, and individuals. This fraud is perpetrated by those looking to access the billions of dollars available for legitimate medical care to patients needing services at all levels. By fraudulently billing for services that were not provided, kicking back monies to individuals, and carrying out other dishonest and unethical practices, individuals have stolen taxpayer funds and potentially prevented people in need from receiving necessary care. This multi-billion-dollar fraud has come under increasingly intense investigation, enforcement, and prosecution by a multitude of federal, state, and local agencies. Through their activities, billions are being recovered. According to the U.S. Department of Justice, more than $2.5 billion was collected in settlements and judgments from cases involving fraud and false claims in the healthcare industry during 2016. For the seventh consecutive year, healthcare fraud recoveries exceeded $2 billion.

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Healthcare leaders must be familiar with the agencies, regulations, statutes, and practice codes that impact the delivery of healthcare. Today’s healthcare leaders must understand the importance of establishing proactive compliance processes and be able to recognize and address potential situations at risk for fraud and abuse.

BY DAY 7 OF WEEK 2

This week, assigned Presenters should post a PowerPoint presentation with a detailed notes section that contains the following:

Incorporation and analysis of the Learning Resources from this 2-week unit, including identification of any apparent gaps in the literature
An original research topic related to the week’s literature (the proposed research topic can be related to the general topic for the week or to gaps in the literature for the week, or it can be related to a specific reading for the week)
Background information on the research topic, including identification of principal schools of thought, tendencies in the academic literature, or commonalities that define the academic scholarship regarding your topic
Evaluation of the main concepts with a focus on their application to business/management practice and their impact on positive social change
A minimum of 10 peer-reviewed, scholarly new references

Note: The presentation must be in APA format and must incorporate direct evidence of addressing the Learning Objectives from this 2-week unit. Each of the content slides must include detailed notes/paragraphs with appropriate citation of peer-reviewed, scholarly references.

list of resources:

Pozgar, G. D. (2016). Legal and ethical issues for health professionals (4th ed.). Burlington, MA: Jones & Bartlett Learning.

Chapter 2, “Contemporary Ethical Dilemmas” (pp. 66–120)

Chapter 13, “Patient Abuse” (pp. 417–436)

Allen, L. P. (2013). Fighting Medicare fraud under the False Claims Act. Health Law Litigation, 10(2), 2¬–6. Retrieved from http://www.americanbar.org/publications/litigation…
Note: You will access this article from the Walden Library databases.

Beimers, T., Disenhaus, J., Kanner, S., Smith, C., Trilling, H., Wisor, R., Andonova, E., Furlow, A., & Thiess, D. (2017). OIG finalizes wide-ranging amendments to civil monetary penalties regulations and Anti-Kickback Statute safe harbors. Journal of Health Care Compliance, 19(1), 9–52. Retrieved from https://lrus.wolterskluwer.com/store/products/jour…
Note: This article is 8 non-consecutive pages in length. You will access this article from the Walden Library databases.

Holland, R. (2014). Of discounts and dangers: Swapping, discounting, and the Anti-Kickback Statute. Journal of Health Care Compliance, 16(1), 37–40. Retrieved from https://lrus.wolterskluwer.com/store/products/jour…
Note: You will access this article from the Walden Library databases.

Mathews, C. (2015). The hospital readmission reduction program: Fraud and abuse concerns. DePaul Journal of Health Care Law, 17(1), 31–46. Retrieved from http://via.library.depaul.edu/jhcl/
Note: You will access this article from the Walden Library databases.

Pham, G. (2015). 2014 healthcare False Claims Act developments. Health Law Litigation, 12(2), 5–9. Retrieved from http://www.americanbar.org/publications/litigation…
Note: You will access this article from the Walden Library databases.

Sidhu, A. S. (2015). The growing threat of qui tam litigation against healthcare providers. Health Law Litigation, 12(1), 12–19. Retrieved from http://www.americanbar.org/publications/litigation…
Note: You will access this article from the Walden Library databases.

Westling, C. R., Walsh, T., & Nelson, W. A. (2017). Perceived ethics dilemmas among Pioneer accountable care organizations. Journal of Healthcare Management 62(1), 18–27. Retrieved from https://www.ache.org/pubs/jhm/jhm_index.cfm
Note: You will access this article from the Walden Library databases.