[Expert Solution]: HIPAA’s definition of fraud is broad

HIPAA’s definition of fraud is broad. Under HIPAA, to be guilty of fraud, a physician’s office need to only present a claim to a federal or state health care program that they should have known would lead to greater payments than appropriate. Sometimes, even good-faith entries that lead to overpayment (defined as abuse) can lead to a review of the claim by the Office of Inspector General (OIG). If there is a pattern of this type of thing, there may be sanctions, which are usually triple the overcharged amount plus up to $20,000 per violation. This is why it is very important to ensure a claim’s accuracy. Review each scenario and choose the most appropriate response. Keep in mind the importance of avoiding any actions that could be considered fraudulent. Question A patient receives a bill because a claim has been denied for service. They ask, “Can’t you just change the diagnosis?” How can you help a patient when the insurance company will not reimburse for procedures reported with certain diagnosis codes? Responses Explain that their insurance company will not cover it, and there is nothing you can do. Explain that their insurance company will not cover it, and there is nothing you can do. Change the diagnosis codes for them. It is important to make sure patients are satisfied with the outcome. Change the diagnosis codes for them. It is important to make sure patients are satisfied with the outcome. Explain the reasons for any inconvenience, then change the diagnosis codes for them but make a note that the codes were changed per patient request. Explain the reasons for any inconvenience, then change the diagnosis codes for them but make a note that the codes were changed per patient request. Double-check the medical documentation, and ask the physician if you are unsure. Explain that diagnosis codes are based on documentation and can’t be changed just to get payment.