Health

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types of questions to ask in the management:

1. How do you relate with your staffs?

2. How ethical are your staffs?

3. What industrial action do you take in handling fraud and abuse issues?

4. Do you inspect the billing of the service you offer?

5. How frequent do you inspect?

Determining if the allegations are substantiated or unsubstantiated:

The criteria to determine if substantiated or unsubstantiated

A Substantiated finding means any complaint or incident that has sufficient evidence to support that the event occurred. However, substantiated does not mean that a federal and/or state violation occurred.

An Unsubstantiated finding is any complaint or facility self-reported incident where evidence does not support the event occurred. A finding that is unsubstantiated can be due to the fact that an incident did not occur or lack of sufficient evidence to support that it did occur.

How to develop a correction action plan

1. A recommendation for a subsequent audit or follow-up to the complaint and determination of when this is necessary.

It is recommended that a subsequent audit or follow ups be made to the health facility to ensure that things are running as expected. It should not be until a complaint be raised but the management should set up a team that is mandated to check on the billing of services to ensure that no single individual is billed for what has not been done. The follow ups will also ensure that the cord of ethics of the staffs is put on notice hence an improved service delivery will be achieved.

2. A recommendation to refund any overpayments to federal government, insurance company or individual payer and when that may be the best course of action.

A refund to the individual is the best action to be undertaken for the health facility to maintain its name.