澳洲邦德大学作业代写 支付和追逐

历史上，医疗保险一直使用“支付和追逐”的方法，这意味着支付索赔，然后进行调查，以确定任何不适当的或欺诈性的支付。这种方法使提供者能够很容易地提出欺诈性索赔并继续进行操作。CMS于2011年推出了欺诈预防系统，该系统通过分析数据来识别潜在的欺诈索赔。预付款审查审计是FPS用来识别欺诈索赔的一种方法。当预付款审查计划的试点启动时，一半的供应商在他们的收费模式上出现了变化。虽然CMS仍然主要依靠“支付和追逐”的方法，其他方法也被用来确保高风险的提供者没有被纳入医疗保险计划。例行的现场检查(有些是未经宣布的)、定期的许可证验证、所有者的指纹识别和犯罪背景检查也已经到位，导致50万医疗保险提供者被清除。随着每天有10万美国人有资格享受医疗保险，CMS进一步加强其欺诈预防系统是至关重要的。最常见，但较少公开的欺诈和滥用案件是违反《虚假申报法》(FCA)。违反FCA的行为包括但不限于:对未提供的服务进行计费，对过多的服务单元进行计费，对错误的程序代码进行计费从而导致更高的补偿，以及对缺乏医疗必要性的索赔进行归档。为了证明已经发生了违反FCA的行为，控方律师必须出示证据，证明被告有意实施欺诈行为，并且应该知道这是错误的。在FCA所列的违规行为清单上还增加了不偿还内部认定为多付款项的款项的行为。对一些供应商来说，由于索赔申请的复杂性，确定超额付款可能不是显而易见的。一些供应商故意错误地提交索赔。目睹这种行为并挺身而出的员工被称为告密者。FCA还允许检举人提供有关虚假索赔的信息。任何追回的资金都会与举报人分享，作为一种激励。

澳洲邦德大学作业代写 支付和追逐

Historically, Medicare has used the “pay and chase” method, which means claims are paid and then investigated later to identify any improper or fraudulent payments. This method has enabled providers to easily file fraudulent claims and continue to operate. The Fraud Prevention System was put into place by CMS in 2011, which analyzes data to identify potentially fraudulent claims. Pre-payment review audits are one method the FPS utilizes to identify fraudulent claims. When the test pilot of the pre-payment review program was launched half of the providers involved showed a change in their billing patterns. Although CMS is still primarily relying on the “pay and chase” method other methods are also used to ensure high risk providers are not enrolled in the Medicare program. Routine site visits (some unannounced), periodic licensure verification, fingerprinting of owners, and criminal background checks have also been put into place which resulted in the purging of 500,000 providers from the Medicare program. With 100,000 Americans becoming eligible for Medicare every day, it is of utmost importance that CMS further strengthen their Fraud Prevention System.The most common, but less publicized cases of fraud and abuse are violations of the False Claims Act (FCA). Violations of the FCA include, but are not limited to: billing for services not provided, billing for too many units of service, billing for incorrect procedure codes which results in higher reimbursement, and filing of claims with lack of medical necessity. In order to prove a violation of the FCA has occurred, a prosecuting attorney must show evidence that the accused intended on committing the fraudulent act and should have been aware that it was wrong. Also added to the list of violations included in the FCA was the act of not repaying funds internally identified as overpayments. To some providers, identifying overpayments may not be blatantly obvious due to the complexity of claim filing. Some providers do intentionally misfile claims. Employees who are witness to such acts and come forward are called whistleblowers. The FCA also allows whistleblowers to provide information regarding false claims. Any funds recovered are shared with the whistleblowers as an incentive.