Healthcare: Health Insurance and Fraud E. Ethical

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Fraud, Waste and Abuse in the Medicare System: A Proactive Approach

Course Project Outline

Team A: The Prairie State Bulls
Julie GIldemeister
Elena Hallars
Teresa O’Brien
Latia Phelps
Laura Wimberley

HSM 546 Health Insurance and Managed Care
Vernice Johnson-Warren
Keller Graduate School of Business Management
March 17, 2013
Synopsis
We propose to discuss the problem of fraud, waste and abuse in Medicare and Medicaid from the viewpoint of a board of directors of a community healthcare system. We agree that a proactive course of action, while initially more expensive, will result in a far better outcome for the system, its providers, and its patients. It will lead to better relations not only with the government but also with our commercial MCO plans. This issue will be addressed on several fronts: legislative loopholes, weaknesses in electronic technology, ethical lapses on the part of providers, and enforcement failures.

I. Executive Summary
A. Environment
B. Rules and regulations of Medicare and Medicaid
C. Healthcare Reform Legislation
D. Problems with Fraud
E. Ethical Considerations of Fraud

II. Problem Statement
A. Fraud, waste and abuse in the Medicare and Medicaid system
B. Legislative loopholes
C. Weaknesses in electronic medical records
D. Ethical lapses in providers
E. Common errors in billing and coding
F. Enforcement failures

III. Literature Review
A. Course text
B. Fraud, waste and abuse of Medicare/Medicaid funds
C. IT and EMR issues
D. Ethical training of providers
E. Enforcement failures

IV. Problem Analysis
A. Identification of opportunities for fraud in a healthcare system
B. Enforcement of Medicare/Medicaid claims reporting regulations
C. Counteracting or preventing a climate of fraud waste and abuse

V. Solutions and Implementation
A. Streamlining enforcement efforts
B. Tightening IT loopholes
C. Creating provider incentives...
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