Fraud and Abuse What is the difference between fraud and abuse? Fraud occurs by

Question

Fraud and Abuse What is the difference between fraud and abuse? Fraud occurs by individuals to many people that are engaged as a group that work in secret to defraud the organization. When we consider the groups involved in fraud we can see how organized crime has infiltrated the Medicare Program and represented themselves as Medicare providers and suppliers. Health care fraud can also happen at the individual level. Consider the following scenario and answer the discussion prompts below. Instructions: While working at the medical office where you are a reimbursement specialist, you notice that a Medicare patient has many more laboratory tests done than a non-Medicare patient. Could this be a case of fraud or abuse? Why or why not? Is it appropriate to notify your office manager? How will you safeguard yourself from getting involved in this type of crime especially if everyone is doing it and it proves highly lucrative? *Note: This Discussion assessed PC-2.3: Demonstrate integrity through the application of relevant codes of conduct and social responsibility within one's profession.

Explanation / Answer

In this case where a medicare patient had more laboratory tests done than a non medicare patient it may be the cause of fraud or abuse if the patient did not receive the laboratory test or if there is insufficient documentation stating why the laboratory test was needed, on the other hand this may not be a cause of abuse because medicare patients are older patients and it is likely that the medicare patient may have more health complications than the non medicare patient, if there is a suspected case of fraud and abuse it would appropriate to notify the officer manager of the issues, to safeguard selfs from getting involved in this type of crime is compile documentations supporting your position, meet with your supervisor to discuss the issues , and also with the department director, to cope this type of situation we should always keep in mind the AHIMA codes of ethics states " the HIM professional refuses to participate in illegal or unethical acts and also refuses to conceal the illegal, incompetent or unethical acts of others" therefore you have a professional responsibility to refuse to participate in or refuse to ignore fraudulent activities.

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