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Essay / Research Paper Abstract
A 5 page research paper that discusses a case scenario involving Medicare/Medicaid fraud via "upcoding" billing practices. The writer discusses ramifications and qui tam lawsuits. Bibliography lists 6 sources.
Page Count:
5 pages (~225 words per page)
File: D0_khquitam.rtf
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Unformatted sample text from the term paper:
performed" (Adams, Norman and Burroughs 430). The term derives from the fact that Medicare and Medicaid payment is allocated according to a set of code, which have different payment rates.
By using the higher codes, the physician is paid at a higher rate. When "practitioners develop a pattern of selecting a higher level code for a lower level service, thats
upcoding" (Adams, Norman and Burroughs 430). The medical documentation in the patients record should provide documentation of the services received in order to avoid allegations of fraud. The scenario
presents the assumption that the physician is fully aware that of the upcoding fraudulent billing and that the office manager is simply following the physicians instructions. However, in todays busy
healthcare environment, experts indicate that many practitioners "rely on office staff and billing companies to process their medical bills without ever reviewing the bills" before they are submitted for payment
to the government (Adams, Norman and Burroughs 430). The guidelines for how to use the billing codes are updated by the government periodically. For example, in 2002, for code 99215,
documentation should show that the patient received an examination of "19 elements or more from at least nine (organ) systems" (Adams, Norman and Burroughs 430). It is possible that the
doctor is simply unaware of changes in the coding system, but, for the purposes of this paper, it will be assumed that the errors are intentionally fraudulent. The False
Claims Act, which is also known as the "Lincoln Law, was enacted initially just after the Civil War in order stop the fraud that was being perpetrated by the companies
that sold the Union Army its supplies ("History of the Law"). From its inception the False Claims Act included "qui tam" provisions , which allows private citizens to sue businesses
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