HSM 420: Managed Care and Health Insurance
Professor: Bob Vega
DeVry University
Tina Neewray
04/2/16
Managed Care and Health Insurance
I.
What is Managed Care
A.
Improper payments from CMS
B.
Underutilization of services
C. US healthcare system
1.
2.
Fee for service
Extensive high medical care and administrative cost
II.
Medicare and Medicaid programs
A.
Underutilization of services
1.
B.
Public healthcare
Program integrity program
1.
III.
Monitoring program
Claim and submission program
A.
B.
C.
Balance billing
Double billing
Inflating the bill for services
References
Barnes, Walter. (2000). “Guidelines for Addressing Fraud and Abuse in Medicaid Managed
Care”. Retrieved from:
https://www.cms.gov/Medicare-Medicaid-Coordination/FraudPrevention/FraudAbuseforProfs/Downloads/GuidelinesAddressingfraudabuseMedMngdCare.pdf
Rudman, William J., (2009). “Healthcare fraud and abuse”.
Retrieved from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2804462/
Fraud and abuse in healthcare.
To begin with fraud is the practice of deception or misrepresentation of facts intentionally which
can result in unauthorized benefits or payment while abuse is improper or inappropriate actions
that are outside professional standards or conduct. Example of fraud may include falsifying
claims or medical records and billing services at higher level than the provided where as an
example of abuse can be failure to maintain satisfactory medical records or refuse to allow
access to medical records.
In this case, in United States, St Jude Medical. Inc. agreed to pay $16 million shillings in order to
silence the allegations that involved paying kickbacks to physicians. This was according to a
whistleblower who was able to give comprehensive inside information on the nature of
kickbacks which ranged from sporting event to entertainment and therefore the relator was
awarded $2.64 million shillings
Another example of fraud case is traced back in December 2014 where Jacqueline Tuangui who
owns Hexam healthcare is facing charges for allegedly exchanging an elderly patients referrals
for unnecessary treatment with kickbacks. This is according to the FBI statement.
Finally, another case is where pharmaceutical manufacturer Warner Chilcott paid kickbacks to
doctors and other professionals in healthcare so that they can go ahead and prescribe drugs like
Asacol, Atelvia, and Loestrin among others.
However despite such fraudulent activities being present, there are several methods that can be
employed to overcome them. Some of the methods are listed below.
The federal Anti-Kickback should prohibit any unnecessary methods, actions or receipt of
money or property in order to induce the referral of patients. Harsh measures should be applied
to those practicing them like jail term for long period of time.
Supporting a nationwide platform of electronic that can search double payments, any
fraud claims, and patient’s Medicare.
Analyzing healthcare payment data from both government and private payers across an
industry owned network to detect waste and fraud.
Medical underwriting is where medical or health information is used in evaluating a coverage for
an applicant usually for health or life insurance. In underwriting process, health information of
an individual can be used to make decisions such as whether to offer or hold back a coverage and
what premium rate should be applied to set the policy while rating uses underwriting
information. Below are differences between underwriting and rating.
Rating uses information gathered through underwriting in order to calculate the specific group or
individual premium. Here the premium calculation is usually done using a rate formula,
predictive writing tools, historical experience and sometimes combinations of all the three above
while underwriting uses health information of an individual in determining or evaluating
coverage such as health insurance or life insurance.
However, when using rate development formula, there are several key elements that are
incorporated. They incorporated elements are listed below;
Population: This includes information like commercial, Medicare, and Medicaid.
Set of covered services which includes service specific limits.
Demographic information like age and gender.
Degree of healthcare management.
Occupation/ industry.
Coverage effective date.
Health status
Geographical area.
Average members per contract.
Set of cost sharing provisions.
Set of reimbursement arrangements.
References:
Essentials of Managed Health Care. (n.d.). Retrieved February 07, 2016, from
https://books.google.co.ke/books?id=MZoTlm3wFhsC.
Healthcare fraud in 2015: Running list. (n.d.). Retrieved February 07, 2016, from
http://www.healthcarefinancenews.com/slideshow/biggest-healthcare-frauds-2015-running-list?
p=7.
News & Press. (n.d.). Retrieved February 07, 2016, from
http://www.healthcarepays.com/news/3-steps-to-eliminate-waste-and-fraud-in-healthcare/.
