Obtaining additional information as necessary and developing a plan for the investigation:

Obtaining additional information as necessary and developing a plan for the investigation:

Obtaining additional information as necessary and developing a plan for the investigation: What other items are important to the investigation?Conducting interviews with staff, residents and/or management: Delineate the types of questions to ask in the interview.Determining if the allegations are substantiated or unsubstantiated: Identify criteria to determine if substantiated or unsubstantiated.
LASA2 Paper: Corporate Compliance

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LASA2 Paper: Corporate Compliance

Fraud has always existed and is increasing fast in most developed and emerging economies, so that it must be seen as representing a major threat to many organizations in most sectors (Pickett, K. H., 2012). In Medicare, fraud and abuse is a serious problem that must be kept in check to avoid loss of taxpayers billions of dollars and putting at risk health and welfare of medical beneficiaries.

Understanding Medicare fraud and abuse, that is, its meaning, and laws relating to the vice would help a responsible person identify such abusive practices in a facility, and assist in combating them. According to King, K. (2010), Medicare fraud, waste and abuse are characterized by improper payments, over payments and underpayments not supposed to be made, or that were made in an incorrect amount. Estimates of 2009 from Medicare and Medicaid services were billions of dollars in improper payments in the medical system (King, K., 2010).

Medicare fraud refers to making falsiful statements or improper representation of material facts for personal gain that one is not entitled to (Marcinko, D., 2011). The fraud may be committed by an individual alone or it could be a wide operation involving a particular institution or a group. According to Marcinko, D., (2011) some examples of Medicare fraud include among others:

Deliberate billing of services that were not given or supplies that were not delivered. For instance, billing for an appointment in which a patient failed to turn up.
Deliberately adjusting claims forms and/or receipts to receive a higher payment amounts.
Soliciting, offering , or receiving a kickback, bribe, or rebate (e.g., paying for referral of patients in exchange for ordering diagnostic tests and other services or medical equipment).
Deliberate duplication of payments


 

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