· What types of potentially fraudulent or abusive behaviors can occur within hospitals?
· Include an example from a publication or article posted within the last five years.
According to McMacken, 2021 “Fraud is the intentional deception to secure unfair or unlawful gain, or to deprive a victim of a legal right.” while “Abuse is defined as practices that are inconsistent with accepted sound fiscal, business, or medical practices, and result in an unnecessary cost or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.” According to Rudman et al., 2009 Healthcare Fraud and abuse accounts for about 3 to 15 percent of annual expenditures in the United States which amounts to about $100 – 170 billion annually. Some examples of healthcare fraud and abuse include misrepresentation of the type or level of service provided, misrepresentation of the individual offering the service, misusing codes on a claim, or billing for services that were not medically necessary. “Raritan Bay Medical Center agreed to pay the government $7.5 million to settle allegations that it defrauded the Medicare program, purposely inflating charges for inpatient and outpatient care, artificially obtaining outlier payments from Medicare.” (Rudman et al., 2009)
· Describe how accreditation helps improve the quality of care delivery process.
· Provide an example for a hospital or hospital system.
Accreditation is the process in which healthcare organizations are evaluated by an independent organization to demonstrate their ability to meet predetermined criteria and standards. The AAAHC, The Joint Commission, and the National Committee for Quality Assurance are examples of Healthcare accreditation organizations that create a set of standards with the help of industry experts. These are the standards that healthcare organizations need to comply with to maintain accreditation status. According to the CDC, Healthcare accreditation is important for several reasons including:
· Stimulate quality improvement (95%)
· Improve accountability and transparency (89%)
· Improve the capacity of the department to provide high-quality programs and services (85%)
· Strengthen the health department’s relationship with key partners in other sectors (e.g., healthcare, social services, education) (78%)
· Help the health department use health equity as a lens for identifying and addressing health priorities (73%)
· Increase the extent to which the health department uses evidence-based practices (68%)
· Strengthen the utilization of resources (68%)” (CDC, 2022)
An example of a hospital accreditation is The Joint Commission’s Gold Seal of Approval. According to The Joint Commission receiving a Gold Seal of Approval means that the facility meets The Joint Commission’s rigorous performance standards in delivering quality, safe care. “St. Luke’s has earned The Joint Commission’s Gold Seal of Approval® for
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