Health Insurance Rules


 Health Insurance Rules

Recently, Sarah travelled to the United Kingdom on a vacation with her family. A few days into the trip, she became very unwell and was advised to return home immediately when suddenly she was told that her doctor’s appointment would have to wait while she stayed in hospital. What followed were many long days of waiting for test results and treatments while Sarah was unable to get back home as they were no longer able to accommodate an out-of-country patient.

As soon as Sarah was able to leave hospital, she quickly purchased a travel insurance policy paying only $10 to get the rest of her trip back home covered, should anything go wrong. Unfortunately, at this point, she was so sick that she missed her flight and had to rebook it for several days later. It was then that they learned they had no coverage for cancellations and inaccurately advised her to take a later flight costing more money. By the time they reached home, her body had healed enough to fly but were unable to afford the extra fee on top of what she already paid for her flight.

Sarah’s story is one of many happening across Canada each year. With the current state of our health care system, Canadians are forced to pay out of pocket for medical services that are covered by provincial health insurance plans in other industrialized countries.

In 2017, the World Health Organization ranked Canada 35th overall in terms of the quality of healthcare across the 34 countries surveyed. In addition to this, Canadian patients pay some of the highest prices for common prescription drugs at approximately $42 per prescription. Canada also has one of the lowest life expectancies among industrialized countries and an infant mortality rate that exceeds those in Japan and Italy .

Canada’s fragmented health insurance system and soaring costs are not only placing an immense strain on individuals but are becoming a significant problem for business owners who have young employees.

The Current Problems with the Canadian Health Care System

In Canada, there is a wide disparity when it comes to health care services across different provinces. Although the government provides some healthcare services for free, many Canadians will have to pay for additional medical services out of pocket. Due to this, Canadian citizens living in some provinces often travel outside of their home province for medical purposes. Individuals may also purchase private insurance or rely on private clinics if they are unable to sustain timely access to public health care services . Unfortunately, billing and payment within the system can be time consuming and costly due to paperwork and processing errors that result in additional charges for patients.

Author: Robert Darby

Articles related to Health Insurance Compliance - What is the Purpose for which It is Used?
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Healthcare compliance refers to the responsibility that health care providers have in making sure that they meet all legal requirements when dispensing controlled substances, as well as maintaining accurate records regarding their use. Drug trials must be registered with Health Canada, and physicians must submit claims for services rendered.

There are a number of rules about maintaining accurate records. Physicians must enter into the system electronically, in chronological order. This means that all requests and claims for services must appear chronologically. For example, a physician noticed the same patient twice in the same day – once on Friday and again on Monday – so they must either enter a medical claim twice or change their record to reflect the second visit.

Dispensing doctors must ensure their accurate records are up-to-date, accurate records of receipt of drugs and claims for services rendered. When you have an account with your drug company or pharmacy, you can log in through your online account to view any approved transactions that have been conducted within your system. If you have any questions or concerns about the accuracy of the information in your paper records, you can also log in and review this information.
One of the most important parts of healthcare compliance is physician order entry (POE). Having a POE system is key to maintaining an accurate record of all controlled drugs prescribed to patients. Some physicians may choose to use an online provider portal that includes automated record keeping, automated prescriptions and can assist with other aspects of HIPAA compliance as well. This will help physicians maintain accurate records regarding patient care.

Healthcare fraud refers to the deception (fraud) that people use when obtaining money from private health insurance programs such as Medicare and Medicaid within the United States. The prevalence of this type of fraud has risen rapidly over the last 20 years. It is estimated that $60 billion is lost from Medicare each year, and $17 billion from Medicaid.
A 2006 report by the Government Accountability Office (GAO) states, "The Government Accountability Office has identified a number of significant deficiencies in Medicare's efforts to detect and prevent health care fraud affecting the federal program." In 2011 alone, more than $15 billion dollars have been lost through fraudulent billing originating from hospitals and doctors offices. There are also other forms of fraud that occur frequently such as billing for services not delivered or services that were never rendered. Most often these types of crimes are committed by professionals in medicine and dentistry .

The types of fraud are as follows:
There are also a number of other forms of Medicare fraud that occur that are not discussed in this article. Health care fraud is illegal, and it is not just perpetrated by dishonest doctors. Criminals will target any businesses that have access to government money and attempt to scam them out of their money.

As a healthcare practitioner, you may be more at risk than you think . Scammers are constantly out there trying to trick people in order to get their hands on the thousands of dollars that go through Medicare programs every day. Some of these scams can be relatively easy to spot, others are extremely complex and detailed. If you are a healthcare provider, it is important that you remain on top of the many schemes that are used in order to protect your company and your personal identity.

In 2010, Ohio’s Medicaid Dental Program was breached by a dentist office with the intention of submitting fraudulent bills for Medicaid claims. The dentist office was caught when one of their patients reported that no services were provided . An investigation later revealed that the group submitted multiple false claims for payment through Medicare and Medicaid. According to the lawsuit filed by Ohio’s Attorney General, their scheme involved creating false patient records .

Conclusion: Protecting your company from the risks associated with healthcare fraud is not only a job for your IT team. It is essential that you, as a healthcare practitioner, be educated and aware of the different types of fraud in order to protect yourself and your practice.

Some of the ways that you can protect yourself include:

There are several different types of surgery centers available in the United States. They provide surgical services either independently or in conjunction with a physician’s office or hospital. Below is a list of some of the most common types.

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