Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Discussion Insurance Fraud For this Discussion board, let’s look at a case study. While working at the medical office where you are a reimbursement specialist, you notice that a Medicare patient has many more laboratory tests done than a non- Medicare patient. Consider these questions in your post to the Discussion board. 1) Could this be a case of fraud or abuse? Why or why not? 2) Is it appropriate to notify your office manager? 3) Would you cite this as possible abuse or fraud and why or why not? 4) Is there a difference between fraud and abuse? Please make sure to site all of your sources of reference.

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Seminar This is the lecture portion of the class. Your instructor will cover concepts from Chapter 2. Topics of Discussion to include: 1.Terms presented in the chapter. 2.Confidential information, HIPPA, and privacy 3.Advantages and disadvantages of the electronic release of information. 4.Examples of fraudulent activities and eight examples of abuse activities. 5.Abbreviations for the six government agencies associated with fraud and abuse prevention. 6.Steps associated with fraud protection and prevention.

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Final Project/Assignment Training for Staff Members This final project is due in Unit 9 but you will want to get started on it early so you can do a great job. One great way to learn something new is to teach it to somebody else. Over the course of this class, you will build a PowerPoint presentation that is 27 slides outlining the major concepts every billing specialist should know. For the Final Project due in Unit 9, you will be completing the a training that outlines some basic. 1.Develop an in-service training session for new billing specialists that covers the concepts you are learning in this course; 2.You should dedicate at least 3 slides outlining these concepts: legal aspects of insurance billing, health insurance concepts, CMS-1500 forms, UB-40 forms, Blue Cross/Blue Shield, Medicare, Medicaid, and TRICARE and CHAMPA. There should be a minimum of 27 slides. 3.Use the Note section as needed to explain terms, concepts, and definitions that you would cover if you were teaching this training. Resources that can help you: Websites found in Extra! Extra! in each unit. eText key terms and review questions. This project will be due in Unit 9 and submitted to the Dropbox

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Quiz Quiz Topics located in doc sharing Quiz time: 1 hour and 30 minutes Review the quiz topics before taking the quiz

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Readings Chapter 2 As an insurance billing specialist, you will come to know many abbreviations. In Chapter 2, you will learn many legal terms and how they relate to your future profession. Remember to take notes and complete the practice activities.

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Unit 4 Tasks Completing CMS-1500 and UB-92 Forms In the Unit 4 assignment, you will be completing both a CMS-1500 Form and UB-92 Form. Both forms are attached below. The criteria for the CMS form is found in exercise 8-4 located in Chapter 8 of your text. The UB-92 form is found in the application exercises of Chapter 9-1 of your text. Please complete each form in its entirety per instructions. Use the CMS-1500 in the assignment section Use the UB-04 form (replace: UB-92) located in doc sharing. The explanation for completing UB-04 form is in Chapter 9 which is located in doc sharing.

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Chapter 2 Legal Aspects of Insurance Billing

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Origin of Legal Issues Local, state, and federal government organizations and agencies Health care agencies must comply with regulations from all levels of government Regulations include everything from building codes to licensing

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Legal Terms Durable power of attorney Power of attorney Guardian Guardianship Emancipated minor

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Legal Terms Embezzlement Malpractice –Malfeasance –Misfeasance –Nonfeasance Negligence

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Legal Terms Employer liability –Respondeat superior Statue of limitations Subpoena Subpoena duces tecum

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Confidentiality Principles –Certain information not open to public inspection –Confidentiality belongs to individual –Individual controls release of confidential information

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Confidential Information Not open to public inspection Laws define confidential information –Medical –Financial –Educational

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Health Insurance Portability and Accountability Act (HIPAA) Federal law enacted in 1996 National standard for protecting certain health information

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. HIPAA Privacy Rule –Defines protected health information (PHI) –Gives individuals right to control use and release of own health information –Applies to covered entities Health plans and health care clearinghouses Health care providers

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. HIPAA Security Rule –Establishes standards for security of electronic protected health information (EPHI) Storage and transmission –Applies to covered entities –Five categories of standards

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Release of Information (ROI) Confidential information –Individual provides written consent ROI form includes –Identification –Time frame –Purpose –Dates and signatures

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. ROI Exceptions to written consent requirement –Patient record subpoenaed –Defend provider in lawsuit –Possible child or elder abuse –Emergency/life-threatening situations –Medicaid or workers’ compensation insurance programs

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. ROI Special considerations –HIV, AIDS, or alcohol or drug abuse –Telephone, fax, Internet, or electronic ROI Form –Section for HIV, etc.

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. ROI HIPAA Privacy and Security Rules –Policies/Procedures protect against unauthorized disclosure or access

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Health Insurance Fraud Fraud –Intentional attempt to receive payment –Federal offense –Applies to any person in position to file claim for Medicare benefits

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Health Insurance Fraud Federal agencies that investigate fraud –Office of Inspector General (OIG) –Federal Bureau of Investigation (FBI) –Department of Justice (DOJ)

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Insurance Fraud Fraudulent activities –Fraudulent diagnoses –Billing for services not rendered –Deliberate medical coding errors Penalties intended to “punish”

Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Health Insurance Abuse Abuse –Unintentional errors that result in improper payments Abusive activities –Inadvertent billing and coding errors –Excessive charges –Unnecessary services Penalties intended to “educate”