The Affordable Care Act (ACA) identifies requirements related to provider compliance with fraud, waste, and abuse laws that have been enacted to protect consumers. Research three of these requirements and describe the corresponding measures that your health care organization has initiated, or could initiate, to comply with the ACA. Support your analysis with a minimum of two peer-reviewed articles.

Introduction

The Affordable Care Act (ACA), enacted in 2010, includes provisions aimed at addressing fraud, waste, and abuse in the healthcare system. These provisions aim to protect consumers and ensure that healthcare providers comply with ethical and legal standards. This paper will examine three requirements related to provider compliance with fraud, waste, and abuse laws under the ACA and discuss the corresponding measures that a healthcare organization could initiate to comply with these requirements. The analysis will be supported by two peer-reviewed articles.

Requirement 1: Development and implementation of a compliance program

Under the ACA, healthcare providers are required to develop and implement compliance programs that contain measures to detect, prevent, and mitigate fraud, waste, and abuse (U.S. Department of Health & Human Services, 2018). These compliance programs should include written policies and procedures, training and education of staff, internal monitoring and auditing, and a process for reporting and investigating potential violations.

In an article by Smith et al. (2016), the authors emphasize the importance of compliance programs in addressing fraud, waste, and abuse. They argue that a robust compliance program can help healthcare organizations identify and rectify potential issues before they escalate into major problems. The authors also highlight the need for ongoing evaluation and refinement of compliance programs to ensure their effectiveness.

To comply with this requirement, a healthcare organization could initiate several measures. Firstly, the organization should establish a dedicated compliance office responsible for designing, implementing, and monitoring the compliance program. This office should have sufficient resources and authority to enforce compliance. Secondly, the organization should develop written policies and procedures that outline the expectations for ethical and legal behavior. These policies should be communicated to all staff and regularly updated to reflect changes in regulations and best practices.

Thirdly, the organization should provide training and education programs to ensure that staff members understand their responsibilities in detecting and preventing fraud, waste, and abuse. Training should cover topics such as proper documentation practices, coding and billing guidelines, and the reporting of suspected violations. Fourthly, the organization should implement an internal monitoring and auditing system to assess compliance with the program’s policies and procedures. This system should include regular audits of coding and billing practices, as well as reviews of documentation and claims data.

Lastly, the organization should establish a process for reporting and investigating potential violations. This process should provide multiple reporting channels to encourage the reporting of suspected fraud, waste, or abuse. It should also ensure that reported cases are thoroughly investigated and appropriate corrective actions are taken.

Requirement 2: Medicare and Medicaid provider screening

The ACA also introduced requirements for Medicare and Medicaid provider screening to prevent fraudulent providers from enrolling in these programs (U.S. Department of Health & Human Services, 2011). The screening process includes verification of provider credentials, criminal background checks, and assessments of past fraudulent or abusive behavior.

In an article by Anderson and Howard (2015), the authors discuss the importance of provider screening in reducing fraud and protecting program integrity. They emphasize the need for thorough background checks and ongoing monitoring of enrolled providers to identify any changes in their status or behavior that could indicate potential fraud.

To comply with this requirement, a healthcare organization could initiate several measures. Firstly, the organization should establish a comprehensive provider screening process that includes verification of credentials, licenses, and certifications. This process should also include thorough background checks, including criminal history, exclusion from other healthcare programs, and disciplinary actions. The organization should also conduct ongoing monitoring of enrolled providers to identify any changes in their status or behavior.

Secondly, the organization should utilize technology and data analytics to enhance the provider screening process. This includes utilizing national databases and tools to verify provider information and identify red flags. The organization should also establish a system for sharing information and collaborating with other healthcare organizations to identify and prevent fraud.

Lastly, the organization should conduct regular audits and reviews of enrolled providers to assess their compliance with program requirements. This includes reviewing claims data, billing patterns, and documentation to identify potential fraudulent or abusive behavior.

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