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Fraud And Abuse In Medicare And Medicaid (Other (Not Listed) Sample)


The goal of the Session Long Project is Assessment and Evaluation of a healthcare organization's compliance with legal and ethical rules and regulations through application of the course concepts and current research to an healthcare organization of your choice. At the end of the session, students shall submit a detailed assessment of the chosen healthcare organization. The final SLP submission shall be no less than 10 pages of text.
For the third component of the SLP, research mechanisms designed to prevent fraud and abuse and compare them to the mechanisms in place at your organization designed to prevent Medicare/Medicaid fraud, abuse and false claims. If you are not currently employed in healthcare, identify a healthcare organization that interests you and research and discuss fraud, abuse and false claims relative to that organization.
Your modular submission need only provide proof of your progress. More in-depth discussion will be required for the final SLP submitted at the end of the course.


Fraud and Abuse in Medicare


Institutional Affiliation

Medicare and Medicaid are one of the largest payers of healthcare services in the world. In the United States, it accounts for 20% of government spending. Therefore, it is necessary that appropriate measures are put in place to curb fraud and abuse in the health facilities. On one side, fraud can be defined as the intentional acts of obtaining payment which someone is not entitled to making false statements or misrepresentations to receive a payment that is not entitled to you. Abuse refers to the incidents and practices that are not fraudulent, but they are inconsistent with the accepted medical business, medical practices and they can result to unnecessary costs either directly or indirectly since they fail to meet the accepted professional standards. I chose the case study of the Health Alliance, Ohio Hospitals and Physician Group where they paid the United States $2.6 million for participating in a fraud in the year 2010.
In the year 2010, the Health Alliance of Greater Cincinnati together with Fort Hamilton Hospital and University hospital- which belong to the alliance and the University Internal Medicine Associates (UIM Associates) paid the United States $2.6 million for violating the False Claims Act and Anti- Kickback Statute. It was reported that the groups took part in a scheme where they referred their patients to UIM Associates so that in return they would begin to cover Fort Hamilton's limited cardiology services that are outlawed in the state law. The State Law stated that Fort Hamilton could only perform the cardiology services after taking part in a clinical trial that mostly involved the procedures. UIM Associates agreed to offer the cardiology service coverage that Fort Hamilton needed for

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