Read the Department of Justice story, “South Jersey Doctor Charged in Health Care Fraud Billing Scheme.” Then, write a 1–2 page report in which you:

1. Summarize three quality issues in the case that resulted in fraudulent billing and coding.
2. Describe three violations that were stated in the case, including how the violations applied based on regulations.
3. Illustrate how this case could be used as a training tool for your organization. You may base your work on the Department of Health and Human Services Office of Inspector General (DHHS-OIG), the Center for Medicare and Medicaid Services (CMS), and the Department of Justice (DOJ) information on quality, fraudulent billing, and so on.

Answer preview

Even among physicians, the increasing need to profit from medicine and insurance company payment limits and government oversight have heightened natural incentives to maximize earnings and reimbursements. When a person visits a doctor or a health care practitioner, each operation or service is assigned a billing code. These codes are used by providers when filing claims with insurance companies or Medicare (Bauder, Khoshgoftaar, and Seliya, 2017). The codes specify the amount of money to be paid to the provider. Because there are so many billing codes, mistakes, errors, and fraud can occur and go unreported for a long

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