Elderly Scams

I think I will need your help on this. I think the billing department did the best to tried to correct all the providers coding errors so we can get paid correctly for all these services. I'm asking for some help on the clinical side and I just receive as a response I can't or she can't. I know that you will be available to found the best way to handle this. We can discuss over the phone later if you wants.

What are the risk factors of elder financial exploitation? In a study conducted by the University of Virginia, there are four predominant types of elder maltreatment. This includes pure financial exploitation (PFE), physical abuse, neglect by others or self, and hybrid financial exploitation (HFE). PFE is elder financial exploitation without any other abuse cited. PFE is usually conducted by unknown individuals to the elderly victim, as in mortgage or home improvement scams. HFE is a combination of elder financial exploitation that includes neglect and/or abuse. HFE usually occurs when the victim is dependent on their caregiver who has power and authority over them. This study addressed the understudied societal problems of financial

When providers or patients submit false or misleading information intentionally to a health plan, this is fraud. Some examples of healthcare fraud and abuse include filing claims for services or medications not actually performed or obtained, billing for services for non-covered items using codes for billable services or items, altering medical records, waiving co-pays and deductibles, up coding and unbundling, using someone’s insurance card, billing Medicare patients at a higher fee than non-Medicare patients, and accepting kickbacks for referring patients, to name just a few. Fraud can be committed by hospitals, medical providers, laboratories, pharmacists, billing services, medical equipment suppliers, and even patients. Patients can protect themselves from healthcare fraud and abuse by knowing their healthcare benefits, reviewing the explanation of benefits, asking the doctor to explain the service that was given, report discrepancies, protect insurance cards and member identification numbers, beware of free services, report copayment and deductibles being waived, and never sign blank insurance forms.

The goal of this deception is to obtain a federal healthcare payment that would not otherwise exist. The provider, practice, or institution may falsely claim to have provided a service or used supplies for a patient when in reality neither the service nor the supplies were used. A secondary way to commit Medicare fraud involves referrals. If one solicits, pays, or accepts money to encourage referrals because the services are reimbursed by Federal healthcare programs, they are participating in Medicare fraud. This type of fraud is addressed in the Anti-Kickback Statute. Lastly, Medicare fraud occurs when the complexity of services are overstated and billed at a higher than necessary rate. This action violates the False Claims Act which protects the government from being excessively charged for goods and services.

Firstly, financial abuse is defined as the illegal or improper use of funds or assets that do not belong to oneself (British Columbia Law Institute, 2011). In a NBC article by Herb Weisbaum (2011), he talks about why the elderly become targets of financial abuse, “Con artists also prey on older people, because as a group they control a tremendous amount of this country’s wealth. And in many cases, poor health — both physical and mental — makes them easy targets for financial predators” (para.

Id. In order for providers to avoid costly claim denials, a risk management and compliance program should be in place and annual monitoring and auditing of internal controls needs to occur on a regular basis. This text will review the issues that medical providers face with coding and billing regulations, the consequences of improper billing and coding, and resolutions that will aid in the prevention of claims being denied.

Some estimate that the federal government loses 30 percent of every dollar it spends on medical claims, due to medical billing mistakes and fraud. With so many loopholes and regulations surrounding Medicare, it is impossible for one person to know every nuance. However, constant diligence and ethical practices are a cornerstone of catching and preventing medical billing mistakes.

It is easy to see how fraudulent medical billing is having a major impact on the Unites States and the citizens of this country who rely on it on a daily basis. We often hear through the various new sources in this country, on the internet or out of the mouths of politicians and experts in the healthcare field about the failing healthcare system in this country. We often hear many different opinions on what needs to be done to fix our healthcare problem within this country and fix what looks to be a very broken system at this point. No matter what the solution to our poor healthcare system is one thing that is very clear is that healthcare fraud and abuse is playing a major role in the depletion of money in this country and the rise in healthcare costs for the citizens of this country.

Common fraudulent practices include billing for services never received, upcoding or unbundling of services, and mislabeling. Billing dishonest services occurs anytime a healthcare provider charges Medicare for a service the patient never received or billing for a more expensive service than performed. Upcoding and unbundling, two examples of billing for a more expensive service demonstrate this fraudulent practice. Simply put, upcoding occurs by billing more expensive codes than the services performed, while unbundling refers to a “bundled” service broken down or unbundled, allowing procedures billed separately to obtain a higher reimbursement than customary. Mislabeling, the practice of substituting non-covered services or products with services or products covered under Medicare guidelines also constitutes fraud. For example, a home healthcare company commits fraud by mislabeling house cleaning services, not covered by Medicare, as a nurse visit in order to receive payment. A pharmacy filling a patient’s prescription with generic drugs and charging for name brand drugs also represents mislabeling.

For example, depending on your employment status or medical situation, you may need very different kinds of assistance from other older adults you know. Some salespeople may even use scare tactics or other below-the-board strategies to pitch their plans, such as free lunch seminars or false claims of being affiliated with a government

Public healthcare applications inclusive of Medicare and Medicaid are particularly conducive to fraudulent activities, as they're frequently run on a price-for-carrier shape.[20] Physicians use several fraudulent techniques to reap this give up. These can consist of “up-coding” or “upgrading,” which involve billing for more high-priced treatments than the ones surely provided; presenting, and in the end billing for, remedies that aren't medically essential; scheduling greater visits for sufferers; referring patients to different physicians when no in addition treatment is really important; "phantom billing," or billing for services now not rendered; and “ganging,” or billing for services to own family members or other people who are accompanying the affected person however who did now not in my view receive any offerings.[20]

WEEP is both unique and promising because the program focuses on education of the elder and their caregiver simultaneously. This combined learning experience will strengthen the elder-caregiver relationship, increase financial knowledge, while improving awareness of fraud and exploitation, thus leading to increased reporting and more prudent behavior. The U.S. Department of Justice and the Department of Health and Human Services outlined in the Elder Justice Roadmap (PBS, 2014) ways in which elder exploitation can be combated through awareness, education efforts to support caregiver(s), and supportive education resources in the community. The Roadmap suggests that there should be better support for the tens of millions of paid and unpaid

Fraud and waste of resources allocated for Medicare pose major risks to the program. Medicare is very vulnerable to a number of frauds majorly due to the fact that the program is hardly audited. Medicare scams occur in various ways that include phantom billing where healthcare providers demand money from Medicare for services not offered. The other form of fraud happens in the shape of patient billing where the patients collude with scammers to claim for kickbacks for false medical treatments. The last type of fraud is the upcoding scheme and unbundling, where bills are inflated by claiming that a patient needs more valuable services or procedures than the existing. The government has been sensitizing the general public on the need to avoid such frauds by not disclosing their Medicare card details to

As the healthcare industry begins to expand its horizons, by featuring more staff and patients, the types of frauds that are committed also rise in number and complexity. One of the many consequences that derives from fraud within the healthcare system includes an increase in the cost of healthcare itself. In order to limit and analyze fraud that encompasses the entirety of the healthcare industry, it is necessary to assess the different types of frauds and in doing so also understand the method of reimbursement involving the professionals and members of the health care industry. Since a majority of these reimbursements are paid by insurances or through government programs, a program known as coding was created in order to organize and properly pay off these reimbursements(Marilyn Price, Donna Norris, 2009). One of the many

There is no doubt that many elderly individuals will eventually need assistance with managing their finances, which includes making purchases on their behalf. Thus the older adult may provide their caregiver with cash, cheques and in some cases they may implement a power of attorney. Essentially, powers of attorney grant considerable power to named individuals, over both finances and property. Unfortunately, over time what evolves is an over spending of the older adults money solely benefiting the caregiver, moreover, these caregivers begin to develop a sense of entitlement (Gibson & Honn Qualls, 2012, p. 27). When considering financial abuse committed by strangers, many simple scams against older adults have surfaced over the years. For example, individuals may offer handyman services, recognizing that many older adults struggle with chores such as exterior window washing. However once paid, the individuals do not return to complete the job. It is interesting to note that of all reported elder abuse cases, financial abuse makes up more than half of all complaints (Friese & Collopy, 2010, p. 60).