ASSIGNMENT

TECHNOLOGY PARK MALAYSIA

CT109-3-1-DGTIN
DIGITAL THINKING AND INNOVATION

NPT1F2309IT

HAND OUT DATE : 09/06/2024

HAND IN DATE : 31/07/2024
WEIGHTAGE : 100%

Student Name : Rojan Sapkota

APU Regd. No. : NP069742
Module Lecturer : Kusum Paudel
 Table of Content

Introduction to Theft and Fraud................................................................1

Explain how and why Theft and Fraud would be Committed....................1

Rules from Code of Conduct to Address Theft and Fraud in Healthcare . .3

Conclusion.................................................................................................5

References.................................................................................................6
Introduction to Theft and Fraud

The phenomenon of theft and fraud is relevant to the field of healthcare and raises
important questions concerning patients’ safety, financial solvency, and the credibility
of healthcare entities. The chief categories of embezzlement entail the unauthorized
taking of property in the form of medical supplies, equipment, or even patient
information, whereas fraud deals with the affiliated acts of deceit, including billing for
services that were never rendered, editing records, and identity theft (Morris & James,
2016). These unethical actions not only waste resources but also threaten the
important role of patient care and information integrity. The repercussions are
numerous and may range from having to pay additional medical expenses to facing
the law and losing public credibility. Solving these problems must include the use of
information security measures, checking for compliance, training employees, and
adherence to legal and regulatory requirements to guarantee the sound delivery of
decentralized healthcare services (Smith & Wesson, 2020).

Explain how and why Theft and Fraud would be Committed

Theft and fraud in this segment are the crucial problems that are also threatening the
credibility and efficiency of the field. Such unethical practices are usually instigated
by the desire to enrich oneself and play a get-rich-quick scheme on identified system
weaknesses.

In healthcare, theft mostly occurs in the form of embezzlement, where the assets that
are usually stolen are medical equipment and products (Smith, 2021). These persons
might include health care workers or other unrelated individuals who take
medications from hospital pharmacies with the intention of using the medication for
themselves or sell them in the black market, thus leaving such items scarce and
irreplaceable in the health facilities. Likewise, medical equipment like surgical
instruments, masks, gloves, gowns, or other PPE may be stolen and resold in the black
market.

1
Healthcare fraud encompasses some of the many deceptive actions that are considered
unlawful, for instance, billing and insurance fraud. Up-coding occurs when providers
seek to claim a higher code that charges more than the service actually delivered or
conduct phantom billing, where providers claim services that were never provided.
Such practices lead to high insurance billing, and part of it is recovered through costs
added to health care bills. Further, the problem of the fabrication of records is
important in the healthcare industry; caregivers can modify the information about
their patients to conceal mistakes in medical practice or to manipulate the situation in
favor of carrying out more procedures, leading to increased insurance payments and a
lower level of patients’ health care (Thompson & Cook, 2017).

One major issue is the accessibility and sale of patient data, especially in today’s
world, with problems in cyber security. Cyber criminals can invade healthcare
organizations’ databases with the intent of obtaining demographic data and other
patient identifiers in order to engage in identity theft or to sell them in the black
market. Internal threats are also an issue since the employees accessing the sensitive
information of patients may use it for their own gain.

All these problems take place when there is poor security, a lack of supervision, and a
high emphasis on revenue generation. Preventing and eradicating theft and fraud
entails the implementation of strict and secure guidelines, third-party reviews, staff
education on proper conduct, and compliance with legal and regulatory requirements.
The effectiveness of these actions is critical for promoting and ensuring reasonable
use of protective measures for the patient’s health, as well as for maintaining the
population’s confidence in hospitals and other medical facilities.

2
Rules from Code of Conduct to Address Theft and Fraud in
Healthcare
1.Strict Adherence to Billing Practices
Rule: Medical practitioners should be aware that all activities related to billing have
to be consistent with the services delivered as well as the legal requirements.

Explanation: Praiseworthy accuracy in billing is important and a core principle in

many codes governing the conduct of practitioners in the healthcare industry,
especially in relation to fraudulent activities and financial misrepresentation. This rule
requires that in billing and code work, the documents and work processes must be
clear, correct, and conform to health care standards. For instance, the AMA Code of
Medical Ethics provides that physician billing practices cannot be deceptive or
fraudulent (AMA, 2020). This rule also has implications because, as per it, medical
care providers must make sure that codes used to bill services are appropriate. This
minimizes the probability of up coding or phantom billing, which are notorious fraud
practices. It is crucial to prevent this rule’s violation through proper training and
constant audits that point out any inconsistencies in the billing processes. This has the
dual advantage of shielding the institution from legal blame as well as avoiding
overcharging patients and insurance organizations.

3
 (Fig 1: Professional Medical Billing Process)

2. Protection of Patient Information

Rule: Healthcare providers also need to have technical, administrative, and physical
measures to protect patient’s records and for the records to be used and disclosed only
when so authorized by law.

Explanation: The privacy of the patient is a primary principle of medical ethics and
common law in most countries and is clearly stated in health knowledge systems such
as the Health Insurance Portability and Accountability Act (HIPAA). This regulation
mandates the adoption of proper measures when it comes to the protection of the
patient’s information. This covers issues such as safeguarding health records in
electronic format, limiting access to such records to only the personnel who rightfully
need them, and, more importantly, providing periodic staff education about ways to
protect the privacy of patient’s information. Thus, the provision of this rule ensures
that access to health information cannot be granted from outside the organization and

4
that data can be easily accessed by an unauthorized person and used for identity theft
and related fraud. For example, to avoid data getting into the wrong hands or being
misused, it is very important that patient data, for instance, be encrypted, and it should
also be made sure that employees observe certain procedures when dealing with
sensitive information (Reynolds & Cohen, 2021). Thus, it is important to follow this
particular rule to be able to preserve the patient’s trust and to conform to the legal
requirements pertaining to the release of any information regarding the patient.

Conclusion

Theft and fraud in the context of healthcare are threats that impact patient lives,
organizations sustainability, and the public’s confidence in healthcare facilities.
Proper billing procedures and the safekeeping of the patient’s details are some of the
standard codes that have been developed to fight issues in the healthcare profession
(Clark, 2023). When it comes to fraudulent claims, timely and correct billing
structures mean that there is a reduced incidence of fake bills being presented, and on
the side of the patient’s identity, the protection of their details curtails cases of
identity theft and abuse. The use of these rules through staff training, monitoring, and
compliance with security features guarantees legal and ethical practices in healthcare
service delivery. Because of these practices, healthcare organizations will be in a
position to reduce risks and the failure of their patients’ trust should they fail to
manage resources properly. In conclusion, to ensure the protection of patient’s rights
and safety and the continual dedication of professionals in the health care setting, each
of these ethical standards is crucial to embrace.

5
References

Morris, L., & James, S. (2016). Healthcare fraud: The need for new remedies. Journal
of Health Care Compliance, 18(4), 23-35.

Smith, J., & Wesson, K. (2020). Safeguarding patient information: Strategies for
preventing data breaches. Journal of Healthcare Management, 65(2), 89-98.

Smith, J. (2021). Strategies for preventing billing fraud in healthcare. Journal of

Medical Practice Management, 36(1), 65-77.

Thompson, A., & Cook, P. (2017). The role of credentials verification in reducing
healthcare fraud. Journal of Medical Ethics, 43(5), 284-290.

American Medical Association. (2020). Code of Medical Ethics: Fraud and Abuse.
Retrieved from https://www.ama-assn.org/delivering-care/ethics/fraud-abuse

Reynolds, T., & Cohen, J. (2021). Theft and mismanagement of medical supplies: A
growing concern. Journal of Health Security, 30(4), 212-225.

Clark, R. (2023). Managing theft and fraud in healthcare: A comprehensive review.

Journal of Health Administration, 41(2), 56-70.