Question

1) upcoding

2) unbundling

3) Prescription fraud

4) Changing a patient’s diagnosis to justify for medically unnecessary services

Choose anyone and explain it and please include the link to your source (article, website) and

what is the potential solution when you approach in any organization?

Answer 1

Prescription fraud

Possessing prescription drugs without a valid prescription. Not all prescription fraud crimes involve planning and deception. You can be charged with prescription fraud for simply having prescription medications without a valid prescription, or with a prescription that is expired.

Forging a prescription. Forging or altering a prescription by any means is a serious crime in Colorado, whether you use a stolen physician’s pad, generate prescriptions with a computer, or alter a valid prescription by changing the name, dosage, or number of refills.

Impersonating medical staff. Another common example of prescription fraud in Colorado involves impersonating medical staff in order to call in prescriptions, and then using your own number as a call back confirmation.

Purchase drugs illegally. Under state law, it is unlawful to purchase drugs illegally over the internet, or from a friend, family member, or dealer.

Filing false police reports. In order to obtain more painkillers and prescription drugs, abusers may occasionally file false police reports claiming that prescription medications were stolen. This practice is considered prescription drug fraud under Colorado law.

Prescribing medications for illegitimate reasons. If you are a doctor or other medical professional, you can be charged with prescription fraud for issuing a prescription for a medication for an illegitimate reason, or outside the course of your medical practice.

Analyzing medical claims often yields clues to prescription fraud. Insurers can help cut back by identifying patients and prescribers who engage in questionable practices. For example, at some Blue Cross and Blue Shield Plans, warning bells go off when members obtain 10 or more prescriptions for controlled substances in a three-month period, or visit three or more prescribing doctors or three or more pharmacies. Blue Cross and Blue Shield Plans then assign a case manager to work directly with these patients to help distinguish individuals who are responsibly managing their pain from those who are abusing medications and may need help.

Blue Cross and Blue Shield Plans also work closely with law enforcement to monitor doctors who prescribe high levels of narcotics and other controlled substances.