Part 1: Medicare and Medicaid Fraud and Abuse Prevention In the United States, as in many other countries, there are mechanisms in place to help prevent medical fraud and abuse. In the United States, any healthcare organization that receives and bills for federal healthcare program funds, including Medicare and Medicaid, are required by law to comply with the federal False Claims Act and any applicable state laws intended to prevent and detect fraud, waste and abuse in federal healthcare programs. This includes, but is not limited to including penalties, statutes, regulations, etc. that are in effect at the healthcare facilities as employees of that facility. This information should be in print form or available online in their policies and …show more content…
The False Claims Act similarly prohibits any person or organization from knowingly concealing, avoiding, or decreasing and/or increasing an obligation to pay or transmit money to the government. “Knowingly” includes having actual knowledge that a claim is false, or acting in “deliberate ignorance” or “reckless disregard” as to whether a claim is false (Health and Human Services, n.d.). Examples of possible false claims include but are not limited to the following: • Billing Medicare for services that were not provided • Billing for services that were provided but were not medically necessary • Submitting inaccurate or misleading claims about the types of services provided • Billing for a hospital service referred by a physician with whom the hospital has a compensation arrangement that violates the Stark or Anti-Kickback law • Failing to timely refund an identified known overpayment received from a federal health program The False Claims Act contains allowances that permit individuals with original information concering federal fraud - that is not currently involved in any legal proceedings or activities that has already been publicly disclosed - to file a lawsuit on behalf of the government and, if the lawsuit results in a recovery, to receive …show more content…
Part 2: Wesley Healthcare Code of Conduct Wesley Healthcare (WHC) works tirelessly to comply with all applicable federal and state laws and regulations that apply to Medicare and Medicaid fraud prevention and abuse. These regualtions and policies govern how employees are hired as well as to their experience and conduct without regard to race, religion, national origin, color, age, disability, sexual orientation, gender, gender identity. Upon hiring, all employees are asked to adhere to the following Code of Conduct while in the employ of WHC. Comprehenive training and evaluation ensures that all employees are following current federal and state regulations regarding how these personally apply to them as a WHC employee. Training is conducted upon hiring and annually for all employees. Some employees receive additional training regarding compliance risk (HCA, 2006) To help in this endeavor, WHC has created a Ethics and Compliance Program headed by Facility Ethics and Compliance Officers (ECOs) to monitor adherence to WHC policies and federal and state