HLT 520 Week 4 Discussion 2 Latest-GCU

What kinds of fraudulent or abusive behavior relating to health care services can occur in hospital operations? How does the role of the compliance committee help to monitor and prevent these?

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Fraudulent behaviors in hospital operations

Introduction

Hospital operations are stressful enough, but when you add fraud, deception or abuse into the mix it can be overwhelming. Whether it’s a patient who refuses to pay their bill or a hospital staff member stealing from you, there are many ways that hospitals can unintentionally commit fraud in their day-to-day operations. Here are some examples of fraudulent behaviors that occur in hospitals:

Fraudulent behaviors in hospital operations

Fraudulent behaviors in hospital operations

• Patient abuse or neglect: The most common fraudulent behavior is patient abuse or neglect. This can take the form of physical, emotional and financial abuse of patients by healthcare professionals. It can also include deception about the quality of care given to a patient and failure to provide needed medication or equipment for a procedure that was not medically necessary.

• Unbundling or upcharging: A second type of fraud involves unbundling (separating) an item from its original packaging in order to sell it separately at higher prices than what they originally charged for their product package deal (e.g., you buy toothpaste at Walgreens but get shampoo instead). Other examples include charging different prices for different items within packages (like $5-$10 when buying food at McDonalds), charging more money than expected after checkout but not telling customers until after they’ve left their credit card info on file so they won’t be able make changes while on site etc…

(1) Charging for non-medical supplies.

• Medical supplies. Examples include:

• Medicine, syringes and needles;

• Anesthetic agents (like lidocaine);

• Oxygen tanks for use in emergency rooms or operating rooms.

(2) Unnecessary surgeries or procedures

There are two types of unnecessary surgeries:

• Non-essential surgery. This is when a patient doesn’t need to have an operation because there is no health problem or injury that requires it, but does it anyway because the doctor or hospital wants to keep their reputation high.

• Cosmetic surgery. This type of unnecessary surgery refers to cases where patients get cosmetic procedures done on their faces and bodies for no reason other than vanity (and in some cases, money).

(3) Unbundling or upcharging

Another fraudulent behavior is unbundling or upcharging, which occurs when a hospital charges more for a service than what is covered by insurance. This practice can lead to fraud because of the fact that it’s not always clear whether or not a patient has coverage and therefore must be charged extra.

This kind of fraud can also cause financial losses for hospitals as well as loss of revenue due to lost business from patients who may cancel their plans after discovering they will have to pay out-of-pocket expenses themselves if they need care outside of their insurance plans’ networks.

(4)patient abuse or neglect

Patient abuse or neglect is a serious issue that deserves your attention. There are many signs to look for when you suspect patient abuse or neglect, including:

• bruises on the skin of patients

• bruises around the eyes and mouth (oral cavity)

• cuts and wounds that do not appear to be from a medical procedure performed by hospital staff.

If you notice any of these behaviors occurring in your workplace, contact your compliance department immediately.

If you notice any of these behaviors occurring in your workplace, contact your compliance department immediately.

The necessity of reporting fraud is outlined below: The consequences of not reporting fraud can be severe and costly.

Conclusion

If you have noticed any of these behaviors occurring in your workplace, contact your compliance department immediately.

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