Fraud and Abuse
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School
University of Cincinnati, Clermont College *
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Course
0223
Subject
Health Science
Date
Dec 6, 2023
Type
docx
Pages
2
Uploaded by ColonelEmuPerson974
Fraud and abuse can be detrimental to a health care organization. Health care managers
play an important role in preventing, detecting, and reporting fraud and abuse. There are a
multitude of ways that a health care organization can commit fraud and abuse including billing
for services not rendered or medically necessary, duplicating bills, assigning incorrect billing
codes for bigger financial gain, and receiving kickbacks. It is essential for health care managers
to have an understanding that fraud and abuse will be legally dealt with by the federal
government and that all members of an organization can be held responsible. This includes
members of an executive team as well. High ranking officers and executives cannot lay blame
elsewhere and avoid any personal responsibility (Buchbinder. Shanks, and Kite, 2021).
Part of the responsibility of a manager in a health care organization is to work with the
board of directors, other managers, and other internal personnel to develop a compliance
program. Compliance programs ensure that organizations adhere to legal and ethical
requirements related to abuse and fraud. Some laws that managers should ensure are adhered by
in relation to abuse and fraud include the Anti-Kickback Statute and the False Claims Act.
Using
the compliance program, organizational policies, training programs, and methods of monitoring
should be developed to aid in decreasing the chances of fraud or abuse occurring (Buchbinder.
Shanks, and Kite, 2021).
In addition to a compliance program risk assessments should also be completed to
determine where the organization is susceptible to fraud or abuse. This is another responsibility
of the health care manager. The utilization of internal controls to monitor billing and coding
practices, employees relationships with suppliers and insurance companies, and any other areas
that could lead to abuse or fraud should be put in place (Buchbinder. Shanks, and Kite, 2021). .
Health care managers also have the responsibility to ensure an organizations employees
are educated on what fraud and abuse is and how to avoid it. This includes ensuring that these
employees have an understanding laws and regulations in relation to fraud and abuse. Training
should occur more than once in the time that an employee is employed by the organization to
ensure the employees do not become complacent.
Depending on the level of manager, responsibilities may lessen or broaden. For example,
an executive may have greater responsibility in terms of resource allocation, policy development,
reporting to the board, etc. A unit manager may have a more direct responsibility in closely
monitoring day to day operations. However, it is essential for all managers to collaborate with
the goal of lessening the chances of fraud and abuse.
Reference
Buchbinder, S.B., Shanks, N.H., and Kite, B.J. (2021).
Introduction to healthcare management.
Jones & Bartlett Learning. LLC.
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