Essay On Health Care Fraud

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.

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]

These providers would also bill for therapy sessions that were really just patient relocations, and billing for a glucose monitor that were not required, so it is easy to see why potential Medicare billing fraud is taken so

There are federal health care statutes that federalize fraud violations. A false claim violation includes knowingly making a false statement or representation of material fact or billing for services knowing that the individual that provided the service was not a physician and may warrant charges as a felony or misdemeanor (Furrow, et al., 2015). The Federal Criminal False Claims Act criminalizes knowingly making a false claim to the United States Furrow, et al., 2015). Criminal sanctions can also include aiding and abetting, conspiracy, and/or mail and wire fraud (Liebert-Hall, 2017). Criminal sanctions require proof beyond a reasonable doubt and proof of intent to defraud (Liebert-Hall, 2017). These laws are in place to promote positive and honest billing practices in health care.

Fraud has many faces and can be found in almost every industry to include Health Care. In all business aspects, there is always the ten percent that finds a way to conduct business the dishonest way and therefore rules, regulations and laws are put into place to keep the honest businesses honest and provide loopholes for those that are conducting business in the gray areas. In the Health Care Reform Law which was signed into law by President Barack Obama in March of 2010, require health care providers to return overpayments by Medicare and Medicaid. In the Act, medical health care providers and suppliers are governed by the stipulations that require them to render repayment from overpayments within 60 days of being identified along with a written explanation of why the overpayment is being returned. When a strong and effective compliance program is in place the rules and regulations of the Health Care Reform law are not a burden on the medical providers.

This thesis is written to provide a historical and policy evaluative perspective on the topic of the False Claims Act and it’s Qui Tam provisions. The False Claims Act is a fairly old Act, dating back to 1863. The Act was first enacted to fight procurement fraud but in recent years the focus has turned to health care fraud. This thesis will seek to determine whether or not the False Claims Act and it’s Qui Tam provisions are an effective tool in fighting fraud, in particular health care fraud. The focus of this thesis will be to evaluate the False Claims Act (FCA) and in particular its Qui Tam provisions. A closer look will be taken at the emergence of a very lucrative type of fraud in the United States. This type of fraud has only been on

Anyone in the medical field may seem trustworthy because most of the time they are. Unfortunately, there are those individuals who seek financial gain and are no longer trustworthy. There is no exact amount of how much fraud has been committed within the health care system, because it usually is never detected. Like in the case of Dr. Guerrero who committed a healthcare fraud scheme against his patients, employees of the health care system, and health care insurances. According to Vivek Pande and Will Maas, Dr. Guerrero was able to commit fraud against clients and the health care system and insurance providers; it is an ingenious crime, because the public considers them intelligent and high achieving individuals. (Pande & Maas, 2013) Overall, health care providers have a choice

Another powerful tool in the effort to combat health care fraud is the federal False Claims Act. In 2015, DOJ obtained over $1.9 billion in settlements and judgments from civil cases involving fraud and false claims against federal health care programs such as Medicare and

As we all know medical fraud and insurance fraud is both a crime, however that does not stop individuals from committing it. Back in 2015 the FBI arrested 46 doctors and nurses across the country. Which was also the largest Medicare fraud bust ever. The individuals billed Medicare for $712 million worth of patient care that was never given. Most of the doctors was ordering durable medical equipment and sending them across the country to patients that did not request nor need them. Since 2007 The DOJ’S Medicare Fraud Strike Force team has gotten over 2,300 people who committed fraud for more than $7 billion dollars. Thanks to the Affordable Care Act there donation has happen catch more individuals .

According to a report obtained by the National Health Care Anti-Fraud Association (NHCAA), in the year 2011 alone, approximately $2.27 trillion was spent on health care and more than four billion health insurance claims were processed in the United States. From just this report alone, we can see that is an undisputed reality that some of these health insurance claims are fraudulent. Although they constitute only a small fraction, those fraudulent claims carry a very high price tag in the end. Health care fraud is a national problem, prevalent in federal and state as well as private insurance programs. From information that the U.S Department of Health and Human Services tells us in this area, it appears that

There are a number of cases that have been tried for fraud and abuse here are a few examples: There was a $6.35 million fraud settlement at Robert Wood Johnson University Hospital Hamilton, NJ. In Sacramento the was a five physicians team that a grand jury indicted in June for running an alleged Medicare fraud scheme worth $5 million. And a Michigan Neurologist was accused of falsely diagnosed seven patients to increase test volumes. All seven were healthy patients so there was a lawsuit but the hospital insisted that his compensation was not due to

Addressing medical fraud, abuse and waste are the part of improving the healthcare system. In order to prevent these issues in the health care system, patient involvement is most important, they should know their benefits and should always receive the benefit statements. Special monitoring should be conducted to detect the evidence of fraud, abuse and waste and strong punishment should be given to discourage others repeating the similar actions.

In 2004, it was reported that healthcare had one hundred fifty billion dollars in losses due to health insurance fraud and abuse. Health insurance fraud and abuse can waste up to one-tenth of healthcare resources. Fraud and abuse also affects the consumer as it causes for the rise in premiums, less benefits, increase taxes and higher copayments. The occurring fraud and abuse also puts patients through unnecessary test and procedures for health insurance claims. Having an aggressive stance on preventing fraud by having a outsourced program established can help prevention in loss and harm to patients. Educating the organization on how much fraud can cost, and that patients are putting trust into the care they receive, expecting to not be deceived.

Billing for services not delivered, a.k.a. phantom billing: Billing fraud is one of the most common types of Medicare fraud. Examples include X-rays and blood tests that were never taken; home healthcare hours never provided; billing for full dental plates when only some dentures were supplied; and services that were supposedly given to patients who already had left the facility or even had

Culture During the 90’s, investors and lenders shifted their interest from a company’s bottom-line to its yearly revenue growth. Furthermore, companies with growing revenues were worthy of receiving investments to finance growth. The shifted focus motivated companies like HealthSouth to transition into practicing more aggressive revenue recognition policies. Aggressive eventually turned illegal when HealthSouth began overstating its revenues.