The present paper is devoted to a case study, which considers providing a compliance roadmap for a healthcare organization that was accused of fraudulent billing and unnecessary service provision in the past. The paper will take into account crucial federal laws and mention the key institutions that are responsible for various regulations pertinent to the problem.
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The elements of compliance with healthcare regulations involve the existence and functioning of organizational tools (transparency policies, legal training, and other mechanisms) that are in line with the law and ensure the identification of risks (prevention) and misconduct (reporting and regulation) (OIGatHHS, 2011). As a health informaticist, the case study professional has determined fraudulent behavior as the key problem of the company’s compliance, and this issue is likely to be resolved through the appropriate update of the mentioned organizational tools.
Thus, the primary activity of the informaticist consists of conducting an extensive study of the existing and desired tools, which can be facilitated by the regulations and guidelines of certain bodies that either issue legislation and regulations or ensure compliance. It is noteworthy that the Office of Inspector General at the Department of Health and Human Services is specifically concerned with enforcing fraud-related regulations (OIGatHHS, 2016). Other anti-fraud bodies include, for example, the Department of Justice [DOJ] (2016).
The mentioned bodies are administrative; in other words, they ensure compliance (enforce the law), for instance, by using the Health Care Fraud Prevention and Enforcement Action Team (DOJ, 2016); also, they produce administrative regulations, which healthcare professionals need to take into account (Sattler, 2017). Other branches of government are also involved in healthcare informatics regulations; in particular, the legislative branch (the Congress) produces statues (Rinehart-Thompson, 2013).
According to Centers for Medicare and Medicaid Services, United States Department of Health & Human Services, and Medicare Learning Network [CMS, HHS, & MLN], the legislation that the informaticist has to take into account includes the Federal False Claims Act, which covers fraudulent claims, the Anti-Kickback Statute, which covers referrals, and the Criminal Health Care Fraud Statute, which covers attempts and actual misdeeds related to healthcare fraud. The informaticist needs to review the policies of the organization and check if they correspond to these laws as well as the applicable state legislation.
Apart from that, some of the activities that are likely to facilitate compliance include the designation of a compliance officer, the provision of extensive training on the topic, the improvement of transparency and intraorganizational communication, and the development of whistleblowing channels and culture (CMS, HHS, & MLN; OIGatHHS, 2011). Naturally, the policies related to monitoring, reporting, and responding to offenses should also be reviewed. CMS, HHS, and MLN (2016) also suggest paying close attention to the relationships of care providers with payers, vendors, and other care providers. The guidelines of the above-mentioned bodies are particularly useful for these activities.
For example, the CMS, HHS, and MLN (2016) provide comprehensive guidelines that are aimed at educating healthcare workers on fraud with respect to Medicare and Medicaid and related health care issues. Such guides and CMS, HHS, and MLN (2016) training programs seem to be particularly useful for improving the awareness of the staff on the topic. This awareness, in turn, is likely to ensure compliance both through increased understanding of a healthcare worker’s responsibility and improved whistleblowing behavior. To sum up, a comprehensive review of the organizational compliance methods in accordance with the existing regulations is likely to be required for the informaticist to resolve the issue of the discovered fraudulent practice.
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Centers for Medicare and Medicaid Services, United States Department of Health & Human Services, & Medicare Learning Network. (2016). Avoiding Medicare fraud & abuse: A roadmap for physicians. Web.
Department of Justice. (2016). Fact sheet: The health care fraud and abuse control program protects consumers and taxpayers by combating health care fraud. Web.
OIGatHHS. (2011). Compliance oversight for health care leaders . Web.
OIGatHHS. (2016). Daniel R. Levinson’s keynote address at the 2016 HCCA compliance institute . Web.
Rinehart-Thompson, L. (2013). The legal system in the United States. In M. Brodnik, L. Rinehart-Thompson, & R. Reynolds (Eds.), Fundamentals of law for health informatics and information management (pp. 17-30). Chicago, IL: American Health Information Management Association.
Sattler, D. (2017). Health law, data privacy and security, fraud, and abuse. In M. Skurka (Eds.), Health information management (pp. 105-142). Somerset, PA: John Wiley & Sons, Incorporated.