ASSIGNMENT DUE IN 48 HOURS
INSTRUCTIONS AND RUBRIC ATTACHED
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48 hours
IR3003: Fraud and Abuse – Analyze insurance and reimbursement cases for potential fraud and abuse.
Written Response Submission Form
Your Name: First and last
Your E-Mail Address: Your email here
Instructions
Write your responses where it reads “
Enter your response here.
” Write as much, as needed, to satisfy the requirements indicated. Each item contains the Rubric, which will be used to evaluate your responses.
Item 1
In your own words, describe the difference between healthcare fraud and healthcare abuse. Explain one state or federal law that is in place to prevent fraud and/or abuse. (2–3 paragraphs)
Your Response
Enter your response here.
Rubric
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0
Not Present
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1
Needs Improvement
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2
Meets Expectations
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Module 1: Healthcare Fraud and Abuse
In your own words, describe the difference between healthcare fraud and healthcare abuse.
LO1.1: Compare healthcare fraud and healthcare abuse.
Response is not present
Response is inaccurate or incomplete.
Response accurately and fully explains the difference between healthcare fraud and healthcare abuse.
Explain one state or federal law that is in place to prevent fraud and/or abuse.
LO1.2: Explain laws aimed at preventing healthcare fraud and abuse.
Response is not present
Response is inaccurate or incomplete.
Response accurately and fully explains one law that is in place to prevent healthcare fraud and/or healthcare abuse.
Item 2
A pharmaceutical company has developed a series of training sessions for providers to learn more about the medications that are offered including the benefits, the side effects, and the dosing. They have had issues in the past with getting providers to attend these training sessions, so they began holding the sessions at high-end restaurants, professional sports team games, and exotic locations. Providers would attend the training and receive a nice meal or admittance to the sporting event after it was complete. This practice has greatly increased participation in the trainings, and they have now started offering additional favors like event tickets, gift baskets, and catered lunches for the office staff.
Do you think that this scenario may be a form of fraud or abuse? Explain. What laws may be violated in this scenario? Explain what can be done by both the pharmaceutical company and the providers to correct the situation. Your response should be 2–3 paragraphs in length.
Your Response
Enter your response here.
Rubric
0
Not Present
1
Needs Improvement
2
Meets Expectations
Module 2: Avoiding Healthcare Fraud and Abuse
Do you think that this scenario may be a form of fraud or abuse? Explain.
LO2.1: Evaluate the legality of healthcare scenarios.
Response is not present.
Response is inaccurate or incomplete.
Response gives an accurate and complete explanation of either the absence or presence of fraud or abuse in the scenario.
What laws may be violated in this scenario?
LO2.2: Analyze healthcare fraud and abuse laws.
Response is not present.
Response is inaccurate or incomplete.
Response accurately and completely identifies any laws that might pertain to this situation and which may have been violated.
Explain what can be done by both the pharmaceutical company and the providers to correct the situation.
LO2.3: Recommend strategies for avoiding criminal activity.
Response is not present.
Response is inaccurate or incomplete.
Response includes an accurate and complete description of how both the pharmaceutical company and the providers can avoid criminal activity by modifying behaviors or practices.
Item 3
The radiology department within a midsized practice was in need of some updated machines. The practice has had some struggles with collecting payments in the past, and they need some additional revenue for these large purchases. The billing department was asked to change the way they code certain procedures and use more complex codes. For example, rather than using the code for a 2-view chest x-ray (71046), they use the code for a 4-view chest x-ray (71048) which bills for a larger amount.
Do you think that this scenario may be a form of fraud or abuse? Explain. What laws may be violated in this situation? Explain what the administrators, billers, or other employees could do to correct the situation. Your response should be 2–3 paragraphs in length.
Your Response
Enter your response here.
Rubric
0
Not Present
1
Needs Improvement
2
Meets Expectations
Module 2: Avoiding Healthcare Fraud and Abuse
Do you think that this scenario may be a form of fraud or abuse? Explain.
LO2.4: Evaluate the legality of healthcare scenarios.
Response is not present.
Response is inaccurate or incomplete.
Response gives an accurate and complete explanation of either the absence or presence of fraud or abuse in the scenario.
What laws may be violated in this scenario?
LO2.5: Analyze healthcare fraud and abuse laws.
Response is not present.
Response is inaccurate or incomplete.
Response accurately and completely identifies any laws that might pertain to this situation and which may have been violated.
Explain what the administrators, billers, or other employees could do to correct the situation.
LO2.6: Recommend strategies for avoiding criminal activity.
Response is not present.
Response is inaccurate or incomplete.
Response includes an accurate and complete description of how the administrators, billers, or other employees can avoid criminal activity by modifying behaviors or practices.
Item 4
Often times, when x-rays are taken at a dentist’s office, they are blurry or do not capture the proper view, so they need to be redone. The biller at a particular dentist office does not bill based on the number of usable x-ray views, but rather on the number of x-rays that were taken for a particular patient. In addition, if any amount of sedation is used (partial or full) for a dental procedure, the patient signs a full sedation consent form, and the procedure is billed with full sedation although few patients require full sedation.
Do you think that this scenario may be a form of fraud or abuse? Explain. What laws may be violated in this scenario? Explain what the dentists, billers, or other employees could do to correct the situation. Your response should be 2–3 paragraphs in length.
Your Response
Enter your response here.
Rubric
0
Not Present
1
Needs Improvement
2
Meets Expectations
Module 2: Avoiding Healthcare Fraud and Abuse
Do you think that this scenario may be a form of fraud or abuse? Explain.
LO2.7: Evaluate the legality of scenarios.
Response is not present.
Response is inaccurate or incomplete.
Response gives an accurate and complete explanation of either the absence or presence of fraud or abuse in the scenario.
What laws may be violated in this scenario?
LO2.8: Analyze healthcare fraud and abuse laws.
Response is not present.
Response is inaccurate or incomplete.
Response accurately and completely identifies any laws that might pertain to this situation and which may have been violated.
Explain what the dentists, billers, or other employees could do to correct the situation.
LO2.9: Recommend strategies for avoiding criminal activity.
Response is not present.
Response is inaccurate or incomplete.
Response includes an accurate and complete description of how the dentists, billers, or other employees can avoid criminal activity by modifying behaviors or practices.
References
Provide a citation for each resource you used to write your response to this Assessment. The following citation has been provided as an example:
· National Health Care Anti-Fraud Association. (n.d.). The challenge of health care fraud. Retrieved May 20, 2019, from
https://www.nhcaa.org/resources/health-care-anti-fraud-resources/the-challenge-of-health-care-fraud.aspx
Mastery Rubric
In order to achieve mastery of this Competency, you must achieve a “2” on every rubric row in addition to meeting the additional expectation indicated in the Mastery Rubric.
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Mastery Rubric
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No
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Yes
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Exceeds Expectations: In-Depth Analysis
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Learning Objective – Analyze scenarios and laws relating to healthcare fraud and abuse.
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Responses to the scenarios do not provide an in-depth understanding of the laws relating to healthcare fraud and abuse as well as the behaviors and practices that help providers and companies avoid criminal activity.
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Responses to the scenarios provide an in-depth understanding of the laws relating to healthcare fraud and abuse as well as the behaviors and practices that help providers and companies avoid criminal activity.
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Professional Skills Building
The faculty Assessor will provide feedback based on the following Professional Skills: Written Communication and Information Literacy. Although the feedback is here to inform the development of your skills, it is not a barrier to achieving the Competency, unless the writing is too poor to be able to score the content of the Assessment. Review the rubric and check your work based on the learning objectives listed. If you are concerned that your writing will not meet these expectations yet, reach out to your Faculty Subject Matter Expert (SME) so he or she can work with you to further develop this important professional skill.
It is highly recommended that you use this opportunity to practice these important skills in the context of this Competency Assessment in order to receive feedback about your current level of proficiency.
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Written Communication: Write with clarity, coherence, and purpose.
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0
Not Present
1
Needs Improvement
2
Meets Expectations
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LO1: Construct complete and correct sentences (AWE 2; Sentence-Level Skills)
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Sentences are incoherent and impede the reader’s access to ideas.
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Sentences are incomplete and/or include fragments and run-on sentences, limiting the reader’s access to ideas.
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Sentences structure effectively conveys meaning to the reader.
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LO2: Demonstrate the effective use of grammar and mechanics. (AWE 2; Sentence-Level Skills)
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Multiple inaccuracies in grammar and mechanics impede the reader’s access to ideas.
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Some inaccuracies in grammar and mechanics limit the reader’s access to ideas.
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Use of grammar and mechanics is straightforward and effectively conveys meaning to the reader.
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LO3: Create cohesive paragraphs with a clear central idea. (AWE 2; Paragraph-Level Skills)
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Paragraphs, or lack of paragraphs, impede the reader’s access to ideas.
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Construction of main idea and/or supporting paragraphs limit the reader’s access to ideas.
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Main idea and/or supporting paragraphs effectively convey meaning to the reader.
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LO4: Use supporting material to support a claim. (AWE 2; Use of Evidence)
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Supporting materials are not present.
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Supporting material is used inconsistently or inappropriately.
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Supporting material is used to enhance meaning. Writing is appropriately paraphrased and uses direct quotes as applicable.
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LO6: Identify sources (AWE 2; Credit to source)
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Sources are missing.
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Writing inconsistently identifies or misrepresents sources.
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Writing clearly identifies the source of nonoriginal material and/or ideas.
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Information Literacy: Apply strategies to evaluate information in order to effectively analyze issues and make decisions.
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0
Not Present
1
Needs Improvement
2
Meets Expectations
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LO1: Identify and locate credible sources.
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No sources or non-credible sources are present.
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Sources are inconsistently credible, appropriate, and relevant to the topic and/or assessment.
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Sources are mostly credible, appropriate, and relevant to the topic and/or assessment.
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LO2: Analyze information sources.
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Analysis is not present.
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Analysis superficially applies aspects of sources that are most relevant to the topic and/or assessment and/or analysis is unclear.
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Analysis thoroughly and clearly applies aspects of sources that are most relevant to the topic and/or assessment.
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LO3: Synthesize information from multiple, credible sources.
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Synthesis is not present.
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Synthesis demonstrates a vague connection between multiple sources and/or the topic.
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Synthesis demonstrates a clear and cohesive connection between multiple sources and/or ideas to support a given topic.
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Inquiry and Analysis: Apply strategies to identify, frame, and evaluate issues and problems.
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0
Not Present
1
Needs Improvement
2
Meets Expectations
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LO1: Identify a problem or question in a selected area of study.
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No problem or question is presented.
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The problem or question is vague or inappropriate to the selected field of study.
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The problem or question is clearly stated in a form appropriate to the selected field of study.
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LO2: Use a logical organizing principle to identify the key parts or elements of a problem or question in a selected field of study.
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Elements or parts of the problem or question are not presented.
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Elements or parts of the problem or question are presented in a disorganized manner.
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Elements or parts of the problem or question are presented in an organized manner.
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