1. How to conduct an investigation. It should include the following elements:
1. Reviewing the initial complaint: What are the items you should look for in a compliant to determine validity?
2. Notifying the appropriate upper management of the complaint unless they are implicated in the complaint: What are the steps to take to determine who is involved?
3. Obtaining additional information as necessary and developing a plan for the investigation: What other items are important to the investigation?
4. Conducting interviews with staff, residents and/or management: Delineate the types of questions to ask in the interview.
5. Determining if the allegations are substantiated or unsubstantiated: Identify criteria to determine if substantiated or unsubstantiated.
2. How to develop a correction action plan. The plan may suggest:
1. A recommendation for a subsequent audit or follow-up to the complaint and determination of when this is necessary.
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.
Assignment 1 Grading CriteriaMaximum PointsDiscussed the process for reviewing the initial healthcare fraud and abuse complaint and the items to look for to determine validity.
-Explained the steps to take to determine who is involved in the complaint.32Discussed how to obtain additional information to develop a plan for the investigation and the items, which would be important to the investigation.-
-Explained how to conduct interviews with staff, residents and/or management and the types of questions to ask in the interview.-
-32Identified the criteria to determine if the allegations are substantiated or unsubstantiated.32Explained how to determine when a recommendation for a subsequent audit or follow-up to the complaint is necessary.
-Discussed the best course of action when a recommendation to refund any overpayments to federal government, insurance company or individual payer is warranted.