(ZPICS) (RAC) and Healthcare Fraud Waste and Abuse



Fundamentally, the practice of auditing started with the concept of oversight in which conventional Medicare auditing commenced with the practice of peer review organizations, commonly known as quality improvement organizations (QIOs) as was formerly established in 1982. and this program was designed to improve both efficiency and quality of Medicare services to the relevant patients. after this enactment, four major areas of Medicare were chosen for the purpose of scrutiny: care transitions, beneficiary protection, prevention and patient safety ((Blumen and Lenderman, 2010). the important legislation in the form of Medicare Modernization Act (MMA) was signed by George W. Bush on December 8, 2003 (About CMS, n.d.). In the following parts of this paper, first, background information has been provided in which basic information about healthcare system, fraud and abuse definitions have been given. It is followed by development segment in which more detailed view of the ZPICS and RACS have been included. Subsequent to that, the HEAT uses have been elaborated in which examples pertaining to HEAT program and efficiency for delivering or satisfying the ultimate objectives of CMS. After this segment, impact section has been included in which the practical effort of these programs on the ground practices has been detailed. Before the summary part, strengths and weaknesses of these programs with regard to fraud, abuse and waste have been elucidated.

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