Medicare Investigations is supposed to make sure that hospitals and other healthcare facilities provide quality care to their patients. However, if providers knowingly provide substandard care or harm a patient through neglect or malicious intent, then they should not be able to hide behind the cloak of Medicare coverage. Therefore, the federal government established an internal system for investigating complaints and flagging suspicious patterns or behaviour. Officers can examine whether the system has been compromised by political manipulation or fraud to find out the real cause of fraud.
When
it receives a complaint about any facility in its provider network – which
includes more than 2 million doctors, nurses, physical therapists, and others
nationwide – Medicaid Investigations will conduct an investigation based upon
whether or not the information provided meets its standards for credibility.
The Medicare investigator is responsible for checking with other hospitals,
talking to the facility's doctors, and cross-referencing complaints with
patient records.
Conclusion
After
the investigation has been completed, Medicare can take one of several actions
based upon its findings. It may issue a letter in which it tells the facility
that it is either completely innocent or that it may be violating Medicare
regulations. If evidence suggests that there may have been violations, then
Medicare will impose a fine on top of the hospital's regular payments from the
federal government. If – after completing this process – the provider is found
to violate federal law, then Medicare can also suspend or even terminate its
participation in the program.
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