Question

Topic: Fraud and Abuse

Thread: Discuss the differences between fraud and abuse. During your discussion, research and describe a recent (within the last 10 years) example and the outcome of each. Next, explain the desirable role of healthcare managers in fraud and abuse cases.

Please include two cited sources as well!

Answer 1

THREAD:

            Fraud has been defined as an “intentional deception or misrepresentation made by a person or an entity, with the knowledge that the deception could result in some kinds of unauthorized benefits to that person or entity” . In general, fraud incorporates the following elements: misrepresentation of a material fact, knowledge of the falsity, one’s intent to deceive, a victim, and then some type of damage to the victim. The limits of fraud can be confused with that of negligence, error, or corruption. However, abuse is the closest concept to fraud. “The degree of intent by the individual or entity is often the determining factor in distinguishing between fraud and abuse”. However this is sometimes easier said than done. “consists of improper acts that are unintentional but inconsistent with standard practices”. The will of the individual, is oftentimes the deciding factor between labeling the action fraudulent or abusive.

            In 2018, the Massachusetts state attorney general filed a 95-page lawsuit alleging fraudulent billings from a community mental health center. The complaint states that by submitting claims to MassHealth for mental health services provided by unlicensed and unsupervised personnel, South Bay Community Services (formerly known as South Bay Mental Health) submitted fraudulent claims in violation of the Massachusetts False Claims Act. Mass Health paid out more than $123 million to South Bay for different out-patient services, such as psychiatric diagnostic evaluations and psychotherapy. “It is estimated that a significant portion of that $123 million was based on the fraudulent claims for services by the unlicensed, unqualified, and unsupervised staff to more than 30,000 MassHealth members. Anyone searching for care or treatment deserves, at least, to be treated by a licensed medical professional. However, South Bay provided substandard care to many vulnerable patients and fraudulently billed the state for its inadequate services. The attorney general’s office was seeking triple damages, civil penalties and prejudgment interest, however the case was settled when South Bay Mental Health agreed to pay $4 million to the Commonwealth of Massachusetts.

            Health care systems seem to be particularly vulnerable to fraud. “Many factors including the asymmetry of information between providers and patients, fixed demand for services, the enormous volume of money spent on health care, the presence of third-party and fee-for-service payments, and the public trust in providers, exacerbate the problem within the health care sector” . As believers, it is important to stand up for what is right and what is Godly. If a healthcare manager notices something wrong, it is their responsibility to report it or fix it. Because of their profession, it is possible that their inaction could affect the lives of hundreds of people. Isaiah 1: 16b-17a states “cease to do evil, learn to do good; seek justice; correct oppression…” In any profession, not just in healthcare, those in positions of leadership are held to a higher standard, and should correct the wrong they see. It’s not too much to ask that people be honest, upstanding citizens, who care for one another and do the right thing. Unfortunately, our world seems to be moving farther away from those basic principles.