Managed Care Organizations And Integrated Health Care Networks

Topic 5 DQ 2

Preventing fraud, waste, and abuse in the healthcare industry is essential to help prevent health care costs from rising. The Affordable Care Act (ACA) is a health reform legislation that was passed in 2010 with the purpose to provide healthcare for all Americans, control costs, and improve the quality of healthcare (Adkinson & Chung, 2014)

Fraud: my healthcare organization monitors documentation, coding, and billing process to avoid misconduct. Continuous monitoring should be done to check (Bentley et al., 2008) :

  • Billing for medically unnecessary services or services not performed. Dig Deeper.
  • Falsifying claims or diagnoses.
  • Participating in illegal referrals or kickbacks.
  • Prescribing unnecessary medications to patients.
  • Upcoding for expensive, medically unwarranted services.

Waste: waste can be prevented by preventing overtreatment or low-value care, pricing failure (Rudman et al., 2009)

Abuse: abuse can be prevented by (Rudman et al., 2009).

  • Ensure accuracy when submitting bills or claims for services rendered
  • Submit appropriate Referral and Treatment forms
  • Avoid unnecessary drug prescription or medical treatment

The Affordable Care Act (ACA) identifies requirements related to provider compliance with fraud, waste, and abuse laws that have been enacted to protect consumers. Research three of these requirements and describe the corresponding measures that your health care organization has initiated, or could initiate, to comply with the ACA. Support your analysis with a minimum of two peer-reviewed articles.

 

Using 200-300 words APA format with at least two references. Sources must be published within the last 5 years. There should be a mix between research and your reflections. Add critical thinking in the posts along with research. Apply the material in a substantial way.

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