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TOPIC for PAPER: Managed Care and Medicaid Fraud

The paper should critically analyze the issues related to the topic and identify key strategies for improvement. In order to meet the project requirements, it is important to identify an issue or problem within the integrated delivery system or managed healthcare organization.

The length of the final paper should be approximately 8–10 pages, double-spaced in MS Word, including a title page (APA style), introduction, APA level-one headings throughout, a conclusion, and a reference page.

Describe a managed care organization or integrated delivery system, and discuss the positive and negative aspects related to healthcare quality, costs, and access to healthcare.

  • Discuss healthcare fraud in relationship to managed healthcare and provide examples.

The paper MUST include the following Sections:

Background

Problem Statement

Literature Review

Analysis of the Problem

Solution of the Problem

Implementation Plan for the Recommended Solution to the Problem

Conclusion With Future Recommendations

References

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Explanation & Answer

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Running head: MANAGED CARE AND MEDICAID FRAUD

Managed Care and Medicaid Fraud

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MANAGED CARE AND MEDICAID FRAUD

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Managed Care and Medicaid Fraud

Introduction
In the healthcare sector, various managed Medicaid organizations have faced an array of
challenges concerning Medicaid fraud. As a result, there has been the consistent research and
examinations on how to tackle this issue. Efforts are made by various institutions that include;
heath care physicians, HIM (Health Information Management), HIE (Health Information
Exchange) as well as to the compliances reached at by the various regulatory bodies that outlines
policies and guidelines in the healthcare sector (Allan, 2015). In the course of the federal
government’s recommitment towards the fight of both the abuse and fraud in the Medicaid
organizations, it is important to note that various roles of the health information experts is
progressively becoming significant as years passes by.
Primarily, during his address to the Congress, back then on 24th February 2009, the then
president of the U.S, Barrack Obama, made a vow to do whatever it takes towards uprooting the
waste, abuse and fraud that exists within the sovereigns of the country’s Medicaid programs. As
a way of backing up this program, the Obama government billed out $1.7 billion implication
over the next five years, to sustain the HCFAC (Health Care Fraud and Abuse Control), in the
financial year, 2010. Besides, the HEAT, Healthcare Enforcement Action Team, created by the
department of justice, rolled out certain requirements that includes;


Improved site assessment particularly to the potential suppliers,



Advanced training expeditions on Medicare fulfillment for the healthcare physicians.



Enhanced data monitoring and sharing amid law enforcement policies as well as to CMS,
and

MANAGED CARE AND MEDICAID FRAUD


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Heightened assessment of Medicaid segments (Phillips et al., 2014).
The weightiness of the government’s contribution towards prosecuting of offenders

related to the fraud and abuse in the Medicaid sector ranges in between various Medicaid
organizations. Examples include Mercy Medical Center, located in Sioux City – Lowa as well as
to bigger organizations like the Pfizer Medicaid Center. In this paper, it takes turn discussing
healthcare fraud in relationship to managed healthcare.

Background
From fraud, to abuse and waste in Medicaid resources, the federal government loses
billions of dollars in each and every financial year. It is a matter that leads to the excessive use of
funds, that would otherwise been used for other selective legitimate healthcare undertakings.
Fraudulent as well as abusive deeds do not only heighten the overall costs of Medicaid processes,
but is also known to supplement no value at all, in the healthcare sector (Phillips et al., 2014).
According to recent research, such practices heighten latent harm and risks to patient, who are
out in the open to unnecessary progressions.
In the fiscal year, 2015 itself, in...


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