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The National Health Service (NHS)

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The National Health Service (NHS)

Introduction

The National Health Service (NHS) is identified as one of the best healthcare system. This is attributable to the National Health Service April 2013 health reforms; which aimed at improving care delivery with fewer resources. These reforms have made improvements in a number of areas in healthcare including funding of the system and patient satisfaction, making the NHS to be more efficient.

Patient choices have been extended to primary care, community care and in mental health services (NHS England, 2014). There has been increased transparency on patient outcomes and data. However, several studies have reported less positive information on National Health Service reforms. According to critics, the benefits and savings being reaped from the reforms is only short term, and that it is not sustainable.

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The progress of the reforms are somewhat disappointing towards establishing a sustainable integrative healthcare services which impeded the establishment of greater use of A&E alternatives, high level completion or greater capacity for outpatient care (Tian, et al., 2012).

For this reason, this article will explore how the NHS reforms introduced in April 2013 have brought changes in the healthcare services. The main reasons behind the introduction of these reforms will also be evaluated. This will facilitate the understanding of development of healthcare systems in the UK, and the State’s roles in changing of the system (Murray et al., 2014).

Additionally, the reasons for recent changes to National Health Service will be evaluated through the analysis of healthcare policies and political perspective in the contemporary health issues in the UK. This facilitates understanding of the various debates and concepts of health promotion, public health, and management of the health services. This paper is planned as follows (Trust Development Authority, 2014);

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Development of healthcare in the UK and Changing of the States roles

The healthcare system in the UK was established after World War II, and began its operations on 5^th July 1948. The National Health Service was proposed in the UK parliament in 1942 in the Beveridge report on Social Insurance (BSI) and other health services allied. The NHS is a bequest of Aneurin Bevan, a previous mineworker who turn out to be the then Minister of Health. NHS was established under the doctrines of impartiality, universality and easy access and delivery of services. The principles were facilitated by a central funding from the government (Alexander, 2013).

In England, the health policy and healthcare is the accountability of the central government. In Scotland, Northern Ireland and Wales, the health care and health policy is the concern of the decentralized governments. In every of the United Kingdom nations, the National Health Service system has its unique structure as well as organization, but has a general organization structure.

Generally, the healthcare consists of two major categories, one section deals with strategy and policy management, whereas the other deals with actual clinical care and medical interventions, which is in turn subdivided into primary care ( General physicians, pharmacists, dentists etcetera), secondary care ( consists of hospice-centred care) and tertiary maintenance (expertise hospitals) (Woringer et al., 2015).

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Recently, the distinction amid the two sections has become less clear. This is attributable to the fact that the last few years have been guided by shifting balance of authority. The other phase and Walness reports have described the gradual changes within the NHS that has resulted into shift towards the local or devolved rather than the centralised decision making process.

The emphasis has been on identification of barriers to effective delivery of the primary and secondary care. This was reinforced by the previous government on 2008 in the strategy dubbed “NHS Next Stage Review: High Quality Care for all” (Cornock, 2016), and “Equity and excellence: Liberating the NHS” 2010 strategy that has remained focus of the current government (Cornock, 2016).

The government has remained supportive of the initial National Health Service principles but possibly through different mechanisms. Recent past, the United Kingdom`s government announced plans to develop strategies that will produce most radical changes in the NHS. The white paper proposed on July 12^th, 2010 “Equity and excellence: Liberating the NHS” aimed at outlining strategies that creates a patient centred and more responsive NHS (Trust Development Authority, 2014).

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Reasons for reforming NHS

The NHS reforms introduced in April 2013 aimed at bringing positive change to the services. Learning from the past mistakes in UK and elsewhere, it was just right time to bring about the fundamental shift to reform the National Health Service. Previously, the UK politics and policy only established short-term political initiatives which were the main hindrances of long-term policy achievements and establishing a sustainable and transformational change. The previous government’s structural reforms were large-scale which acted as major distractions rather than facilitators (NHS England, 2014).

The NHS reforms ensured that such distractions are avoided in the future. Previously, the National Health Service reforms relied on external stimuli such as performance management, targets, quality inspection and regulation, choice and competition. These were too little to offer for improvement from within the health care. This called for a new settlement where the strategic role of a politician could be demarcated clearly. This helped minimize the frequent shift in directions which hindered transformational change (Trust Development Authority, 2014).

Unlike in the past, April 2013 National Health Service reforms did not dwell on bold strokes or politician big gestures, but rather engaged the primary care, secondary care and tertiary care providers. It focused mainly on healthcare staff improvements. The complementary approaches used by these reforms pursued national leadership in combination with devolution, competition and innovative standardization (NHS England, 2014).

The April 2013 reforms focused on transparency, devolution and performance in a systematic manner. The reforms ensured that the improvement in the NH was based on commitment instead of compliance by investing in staff improvement to empower them to achieve sustainable quality improvement. The reforms envisioned a high performing healthcare organization, which indicated continuity in leadership, organization stability and clear goals for improvement in delivery of healthcare services (Woringer et al., 2015).

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Underlying concepts of funding in healthcare

The overall organizational structure of NHS in the National Health Service fiscal support is obtained from taxation. Approximately, 60% of the funds are used for staff salary, whereas additional 20% is used for medical appliances such as drugs, buildings, training costs, and equipment. The principle founders of the NHS system were the NHS primary Care Trusts (PCTs).

They disburse funds to the commissioned healthcare providers such as the National Health Service trusts, General Providers and Private providers according to the agreed contract basis. In public healthcare medical cover, vast of the National Health Service services are free. This implies that UK citizens need not pay anything for doctor visits, nursing services and consumable charges such as medications and laboratory services (Iacobucci, 2015).

The Department of Health have the responsibility for direction of National Health Service, public health and social care and the delivery of care. This includes developing policies and strategic interventions and ensures that they secure healthcare resources. Previously, there are about 10 strategic Health authorities manages NHS at local level, and the PCTs control approximately eighty percent of the NHS budget to provide the commission services and governance, and to ensure resource availability within the public health.

The NHS trusts operate on basis of paying by results (NHS England, 2014). Examples of National Health Service trusts include the Mental Health, Acute care, Ambulance, Foundation Trust and Children’s Trust. The foundation Trusts was developed to increase financial obligations and are monitored by an independent body. These include the Care Quality Commission, National Audit Office, Audit commission, Medicines and Healthcare Products Regulatory Agency, British Medical association, and the National Institute for Health and Clinical Excellence (NICE) (Frisina Doetter & Götze, 2011).

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Evaluation of health policies as well as political thoughts in contemporary health issues

The government has embarked on widespread reform programme which aims at introducing substantial changes in the National Health Service structure and management, and to improve the quality of care delivery. For instance, a number of new changes in NHS was introduced by the April 1^st NHS reforms in England. One of the main changes done by these reforms includes shifting of responsibilities that originally were in the Department of Health, to the politically independent entity- the National Health Service commissioning Board.

The reforms will also establish a health specific economic monitor whose aim is to guard the healthcare delivery from ‘anti-competitive practices. The reforms ensure that all NHS trusts are shifted to foundation trust status (Le Grand, 2013).

The reforms are expected to fill some gaps in the UK healthcare system. According to the April 2013 reforms, the government supports the idea of GP commissioning. This implies that the key decisions of patient’s treatment should be made by GP in partnership with the service user rather than the managerial organisations.

The Strategic Health Authorities (SHAs) and Primary Care Trusts (PCTs). Under the new reform, GPs are integrated in the consortium that controls commission’s services and budgets. However, the NHS commissioning Board is expected to reduce health inequalities so as to access healthcare (Edkins, Cairns & Hultman, 2014).

The government white paper calls for a healthcare system that moves away from the centrally-driven healthcare system to one which focuses on the patient outcomes and the quality of care delivered (Mead, 2013). This devolution of healthcare system implies the five main domains used to assess the effectiveness of the program success are realized.

These includes reduction of premature death, improving the life of people living with chronic diseases, helping people recover from preventable injuries, ensure people easily access better care services equitably and ensuring a safe environment and protecting people from harm (Mead, 2013).

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The reform has been highly criticized warning that the move is creeping towards privatisation of commissioners. The opponents argue that the profit oriented firms could oust GPs from their role of making decision on effective treatments due to the creeping privatisation of primary care.

According British Medical Association (BMA), the reforms would make the relationship between physician and patients will suffer irreparable damages, and the negative impacts will damage NHS irreversibly. According to the BMA, health and social care bill is incoherent, complex and unfit for its purpose. They argue that to sustain the implemented reforms will be difficult (Sussex, n.d.).

The privatisation of commissioning will cause massive effects on public health, as it will is likely to exacerbate health inequalities and loss of accountability. Most of the areas affected by the reforms are about the issue of how money is spent and who makes the decisions. This is because new organizations are being established and others being abolished. The legal responsibility for management of NHS budget will be shifted to new organisations. Local councils are also given higher mandate in matters that influence health services. The suggested performance reforms and finance performance is somewhat daunting (Milburn & Flowerday, 2012).

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For instance, on autonomy, many people believe that the policy landscape is clear. This implies that the NHS Trusts autonomy would be progressively replaced by the independent foundation trusts. According to Cornock (2016), the rising new relationship between commissioners and providers will help bring primary and secondary care closely, which will help merge the transformation and sustainability plans to sustain effective delivery of services (Triggle, 2014).

However, this would imply deterioration of performance and finance as the central control of healthcare budget is extended to include other aspects of healthcare such as operational management and workforce (Murray et al., 2014). As the issue of finance recedes, NHS is expected to invent new approach to sustain the earned autonomy for NHS providers. This is a challenge because the foundation trust model may fail to ultimately protect the local organizations autonomy. Therefore, to reinvent autonomy, the NHS governance and structure will need to be restructured (Woringer et al., 2015).

Conclusion

Despite the fact that the reforms were established to reduce health inequalities, the reforms issues are highly debateable. The government believed that the NHS reforms were the best approach to improve the public health. Clearly, many things as highlighted by BMA have been overlooked. In this context, the NHS needs to make more honest assessment of what can be achieved and ensure that the strategic plans designed are comprehensive and realized.

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References

Alexander, J. (2013). The Tavistock and Portman NHS Trust short course Holding the Baby and Toddler Mind: An individual family and community perspective April 2013. Infant Observation, 16(2), 200-204. http://dx.doi.org/10.1080/13698036.2013.818362

Cornock, M. (2016). Removing rancour in examining mistakes would be new for the NHS. Nursing Standard, 30(30), 30-31. http://dx.doi.org/10.7748/ns.30.30.30.s38

Edkins, R., Cairns, B., & Hultman, C. (2014). A Systematic Review of Advance Practice Providers in Acute Care. Annals of Plastic Surgery, 1. http://dx.doi.org/10.1097/sap.0000000000000106

Frisina Doetter, L., & Gatze, R. (2011). Health Care Policy for Better or for Worse? Examining NHS Reforms during Times of Economic Crisis versus Relative Stability. Social Policy & Administration, 45(4), 488-505. http://dx.doi.org/10.1111/j.1467-9515.2011.00786.x

Iacobucci, G. (2015). Privatisation of cancer and end of life care services in Staffordshire could threaten NHS providers, warn critics. BMJ, 350(mar19 9), h1557-h1557. http://dx.doi.org/10.1136/bmj.h1557

Le Grand, J. (2013). Will 1 April mark the beginning of the end of England’s NHS? No. BMJ, 346(mar26 4), f1975-f1975. http://dx.doi.org/10.1136/bmj.f1975

Mead, J. (2013). Orthopaedics – Allegation of obsolete procedure dismissed: Ecclestone v Medway NHS Foundation Trust (High Court, 12 April 2013 – Judge Reddihough). Clinical Risk, 19(3), 83-84. http://dx.doi.org/10.1177/1356262213497684

Milburn, S., & Flowerday, A. (2012). Delivering scalable Telehealth: What is Scale? With case studies from NHS providers, a perspective on the challenges, constraints and issues associated with scalability. Int J Integr Care, 12(4). http://dx.doi.org/10.5334/ijic.931

Murray, R. et al., (2014). Financial failure in the NHS: What causes it and how best to manage it, The King’s Fund. Retrieved from http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/financial-failure-in-the-nhs-kingsfund-oct14.pdf

NHS England. (2014), Examining new options and opportunities for providers of NHS care: the Dalton Review. NHS England (2014), Five. Retrieved from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/384126/Dalton_Review.pdf.

Sussex, J. (n.d.). How Fair? Competition between Independent and NHS Providers to Supply Non-Emergency Hospital Care to NHS Patients in England. SSRN Electronic Journal. http://dx.doi.org/10.2139/ssrn.2640148

Tian, Y. et al. (2012). “Data briefing: Emergency hospitals admissions for ambulatoryCare-sensitive conditions”, The King’s Fund. Retrieved from http://www.kingsfund.org.uk/publications/data-briefing-emergency-hospital-admissions-ambulatory-care-sensitive-conditions

Trust Development Authority. (2014). Annual report and accounts for the period 1 April 2013-31 March 2014. Retrieved from http://www.ntda.nhs.uk/wp-content/uploads/2014/07/NHS-TDA-Annual-Reports-and-Accounts-201314.pdf.

Triggle, N. (2014). Five-year plan to transform NHS focuses on teamwork. Nursing Management, 21(8), 10-11. http://dx.doi.org/10.7748/nm.21.8.10.s12

Woringer, M., Cecil, E., Watt, H., Chang, K., Hamid, F., & Khunti, K. (2015). Community Providers of the NHS Health Check CVD Prevention Programme Target Younger and More Deprived People. Int J Integr Care, 15(5). http://dx.doi.org/10.5334/ijic.2185

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Mayo Clinic’s Utilization Management Program

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An Overview of Mayo Clinic’s Facility Utilization Management Program

Mayo clinic is a sophisticated health care organization, which runs a variety of health care facilities, medical schools, and health science schools in the United States (Kashyap et al, 2016). This organization has developed an elaborate healthcare facility management program, which is aimed at enhancing the functionality of its facilities and personnel by integrating the most qualified health specialists and staff with a well-designed and equipped environment. Mayo clinic provides health care services to millions of patients from within the country and outside at a reduced cost (Miller et al., 2014).

The health care provider has facilities that are located in some of the following areas; Rochester, Jacksonville, Minnesota, Phoenix, Arizona, Scottsdale and Florida. In fact, its clinical campuses in Rochester are regarded as the world’s most integrated clinical facilities (Kashyap et al, 2016). In Mayo clinic, facility utilization and management program is based on empirical and evidence based strategies, which are aimed at providing the clinicians and other health care service providers with a conducive work environment, and the clients with high quality services, depending on urgency, and in the most appropriate and efficient manner (Kashyap et al, 2016).

Facility utilization management is also regarded as a venture that assists the management to reduce the overall costs of running the facility. It is therefore implemented in a prospective, concurrent, and retrospective approach (Kashyap et al, 2016). The health care provider has also developed the ‘at-risk care delivery program’, which is meant to increase the effectiveness of health care provision to its clients, as well as an enabling environment for the physicians and other staff members.

For instance, the at-risk care delivery program is designed to provide clients with; a well-planned discharge schedule for inpatients; provision of services with minimum variation for all clients; and a continuum of high quality care services to both inpatients and outpatients in the clinic, and all these being designed to result in minimization of any unnecessary care that could be provided to patients, and as such, an overall reduction of costs incurred in service delivery to patients is achieved (Kashyap et al, 2016).

Critique of the Facility’s Utilization Program In Light Of the Standard Utilization Management Programs

Facility Utilization Management (FUM) in this organization is evident in the systems and procedures that it has adopted as an effort to achieve health care savings. In particular, FUM is achieved through effective management of patients’ care as well as minimizing unnecessary care that is given to the patients (Kashyap et al, 2016). Physicians and other medical staff in Mayo clinic have been sensitized to the need to adhere to FUM guidelines as health service providers, as an effort to increase the accountability of medical service provision to patients who are regarded as payers in the system.

As such, they are required to provide health care services in accordance with the patient’s needs and the medical necessity that arises from the need, which in this case should be provided to the patient in the most efficient and appropriate manner at all times (Massimino et al., 2015). To achieve this, Mayo clinic has adopted the necessary technology to oversee efficient and economical service provision to patients including hospital admission programs, length of stay management, and precertification programs (Julianna et al., 2013).

All these programs are designed to provide patients with services in the most economical manner, where costs are aligned with the type of service provided. These programs have been adopted in all areas within Mayo clinic’s health facilities including medical, substance abuse, laboratory, and surgical sectors.

FUM within Mayo clinic is performed retrospectively and concurrently as deemed necessary. The specific objectives include maintaining the average number of patients who receive services, but at a reduced cost; establishing a DRG-guided inpatient health care facility; and to effect free for service outpatient services as a containment strategy to cut down on costs (Kashyap et al, 2016).

In its prospective review programs, Mayo clinic evaluates patients’ perceived medical or care need before admission, and assesses its appropriateness in terms of the proposed service requirement against any available medical information about the patient’s condition. This is followed by conducting an extensive consultation to determine the necessity for the required services or procedure (Julianna et al., 2013). If positive outcomes are obtained, then the patient is admitted for services or provided with outpatient services, if negative, alternative treatment options are discussed with the patient (Kashyap et al, 2016).

The prospective review program may be seen as a cost effective measure since it prevents the patient from being given unnecessary treatment services, and the health facility from incurring costs from the services provided, medicine and consultancy fees for physicians. The likely disadvantage in the program is that prospective reviews are bound to take lots of time if they are to be effective and meaningful (Massimino et al., 2015). In addition, the type of review may not be effective in cases where patients require emergency services, and this is because unnecessary costs would still be incurred during the diagnosis.

In its retrospective review programs, Mayo clinic conducts a detailed analysis of the duration of stay among other metrics in all its institutions and health facilities, including an analysis of the length of stay at the physician(s) level. Retrospective review is aimed at identifying any gaps in care provision, and whether there exist anomalous utilization patterns in the system (Kashyap et al, 2016). The information provided is used to make updates on clinical guidelines and registries according to care outcomes, after which necessary adjustments are made.

The retrospective review may be seen as an important venture because it helps management to optimize the health service outcomes, and at the same time achieve a reduction in the overall costs of operating the clinics. In addition, gaps in the utilization of medical staff and facilities may also be identified through the review, which would allow the appropriate adjustments to be effected. If effectively done, this would be reflected as reduced operation costs.

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In its concurrent review programs, Mayo clinic emphasizes that its physicians and the medical staff screen patient’s conditions or health service requirements before admission, which is a means of determining the medical necessity of the patient’s need requirements (Kashyap et al, 2016). Information from the screening procedure is also used to determine the appropriateness of the patients’ perceived requirement. As an effective care management program, the screening procedure helps determine the appropriate duration required in giving the patient the required service care, and this information is used to schedule the period of stay from admission to when the patient is discharged.

The concurrent review program may be seen as an effective venture in as far as cost reduction in care provision is concerned. This is so because; information obtained from the screening procedure may be used by physicians to prescribe the correct treatment. Specifically, it allows the nurses and medical staff to provide health care services in an efficient manner while focusing on the anticipated outcomes (Kashyap et al, 2016). In this case, wastage of time and medication is minimized; the clinic is also able to anticipate the appropriate bed days for scheduling.

On the other hand, the clinic is able to cut down on costs incurred through bed stays and admission services, which is because the applicability of the provision of home support services may be evaluated during the screening procedures. In addition, the patients are also able to receive high quality services and the needed attention, since the nurses and physicians would need to monitor the patient’s progress in an effort to adhere to the schedule and discharge plans.

References

Kashyap, R., Farmer, J. C., O’Horo, J. C., & Farmer, C. (Eds.). (2016). Mayo Clinic Critical Care Case Review. Oxford University Press.http://books.google.com/books?hl=en&lr=&id=XxQ9DAAAQBAJ&oi=fnd&pg=PP1&d q=mayo+clinic++&ots=PwF_auNEbd&sig=Bj5vKP_jdmz1YhiYaEc4U9IBTBI

Massimino, P. M., Joseph, M. L., & Kopelman, R. E. (2015). Hospital Performance and Customer-, Employee-and Enterprise-Directed Practices: Is the Mayo Clinic Reputation Deserved?. Journal of Management Cases, 28.

Merten, Julianna A., et al. “Utilization of collaborative practice agreements between physicians and pharmacists as a mechanism to increase capacity to care for hematopoietic stem cell transplant recipients.” Biology of Blood and Marrow Transplantation 19.4 (2013): 509-518.

Miller, R. C., de los Santos, L. E. F., Schild, S. E., & Foote, R. L. (2014). Organizational Culture and Proton Therapy Facility Design at the Mayo Clinic. International Journal of Particle Therapy, 1(3), 671-681.

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Quality and Safety in Healthcare

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Quality and Safety in Healthcare

Constant improvement of quality and safety is an important aspect in healthcare. Nurses play an important role in improving quality and safety in healthcare. Be as it may, nurses are always in contact with patients during the entire treatment. Their actions, professionalism, and observation of ethical principles determine the level of quality of service and safety within the healthcare system (Simon et al., 2013).

Nurses need to be committed to offering quality services including offering grief support. Emphasis on good care plans to ensure protocol is followed when offering support to patient can improve the quality of care.

I learned that nursing ethics play an important role in improvement of quality and safety of patients. Nurses are guided by professional principles and ethical framework that ensure that patients are treated according to standard protocol put in place. Nurses are required to be caring to patients and communicate effectively to ensure that patient is comfortable throughout while in the hospital. Respecting other healthcare practitioners and building strong and professional relation could also help improve quality of healthcare (Elwyn et al., 2014).

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Nurses can also ensure that healthcare goals of registering desirable patient outcomes is achieved by ensuring that each individual and family takes part in the care process. By engaging patients and families in the process of care, nurses are able to improve patient outcomes and rates of satisfaction. This is achieved through enhancement of the quality of the associations between the patient, the physician as well as the utilization of diagnostic testing, hospitalizations, and referrals.

Improvement of quality of healthcare can be achieved through observing its structure, processes, and outcomes. Structures essentially validates the availability, accessibility and quality of resources such as number of nurses, bed capacity among others. Nurses can help in improving quality of nursing through observing nursing principles and ethics, working through teamwork and involving family in provision of healthcare services.

References

Simon, B. et al (2013, August). Student experience in a student-centered peer instruction classroom. In Proceedings of the ninth annual international ACM conference on International computing education research (pp. 129-136). ACM.

Elwyn, G. et al (2014). Shared decision making and motivational interviewing: achieving patient-centered care across the spectrum of health care problems. The Annals of Family Medicine, 12(3), 270-275.

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Fraudulent billing

According to the Institute of Medicine 2012 report, the U.S. healthcare system loses 10% of the health expenditure annually due to fraudulent billing. This includes unnecessary reimbursements, inefficient delivered healthcare costs, administrative costs, preventable opportunities that are missed and egregious pricing of services. Healthcare fraud is categorized into provider fraud, consumer fraud and payer fraud (Raghupathi & Raghupathi, 2014).

An example of fraudulent billing is Medicare Fraud. This includes submitting knowingly or forcing submission of false claims or misrepresentation of facts so as to obtain healthcare payment which otherwise one would not be entitled to. Other fraudulent behaviors include soliciting, offering or receiving bribes to induce or to reward referrals for services reimbursed by the federal healthcare systems.

These kinds of frauds range from individual to broad based operations by organizations. Other kinds of fraudulent billing includes charging for bounced appointments, billing services at higher level of complexity than what was actually provided for or billing for services that were not furnished or paying for deliveries that were never done (Fraud abuse, 2016).

The following article was chosen for this analysis is :- Joudaki, H., Rashidian, A., Minaei-Bidgoli, B., Mahmoodi, M., Geraili, B., Nasiri, M., & Arab, M. (2016). Improving Fraud and Abuse Detection in General Physician Claims: A Data Mining Study. International Journal of Health Policy and Management, 5(3), 165–172. http://doi.org/10.15171/ijhpm.2015.196

According to this article, the healthcare fraud account for 10% of the healthcare expenditure. Despite the stringent laws established by the Congress, addressing the healthcare care fraud has become a challenge especially in light of these major economic changes in healthcare market place. According to this article, traditional methods of detecting healthcare fraudulent billing in healthcare are inefficient and time consuming. The article suggests that using automated methods as well as the statistical knowledge has led to the emergence of new branch of science known as Knowledge Discovery from Databases (KDD). One core processes is the Data mining (Joudaki et al., 2016).

Through the data mining strategies, the third party payers such as insurance companies are able to obtain useful information from many claims and are also able to identify the smaller subsets of claims that need further assessment. The article explores the various theoretical and practical challenges associated with the healthcare fraud, as well as the merits of addressing healthcare fraudulent activities.

In addition, the article reviews studies conducted through data mining to detect frauds in health care, where three quarters of the study indicates that data mining technique is an effective strategy in identifying, predicting and preventing fraudulent activities in healthcare. The study concludes that data mining is an effective technique to streamline auditing processes towards the suspected group (Raghupathi & Raghupathi, 2014).

Defrauding the federal government and the medical cover programs is illegal. This could lead to criminal and civil liability and could lead to fines, hefty penalties or imprisonment. The federal fraud and abuse laws that is used against the physicians includes; United States Criminal Code, False Claims Act (FCA), Physician Self-Referral law (Stark law), and the Social Security Act.

These laws describe the administrative, civil and criminal remedies imposed by the government on entities that commit fraudulent billing or activities in Medicare program. Violations of these laws can also lead into exclusion in all federal healthcare programs, non payments of reimbursements, or exclusion from all federal healthcare programs (Fraud abuse, 2016).

References

Fraud abuse (2016). Medicare Fraud & abuse: prevention, detection and reporting. Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Fraud_and_Abuse.pdf

Joudaki, H., Rashidian, A., Minaei-Bidgoli, B., Mahmoodi, M., Geraili, B., Nasiri, M., & Arab, M. (2016). Improving Fraud and Abuse Detection in General Physician Claims: A Data Mining Study. International Journal of Health Policy and Management, 5(3), 165–172. http://doi.org/10.15171/ijhpm.2015.196

Raghupathi, W., & Raghupathi, V. (2014). Big data analytics in healthcare: promise and potential. Health Information Science and Systems, 2, 3. http://doi.org/10.1186/2047-2501-2-3

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