Essay On Health Care Fraud

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

False claims are a parasite to the American health care system resulting in overall higher health care costs. The Department of Justice reported recovering $1.9 billion dollars in fiscal year 2015 from fraudulent and false claims in health care (Department of Justice, 2015). In 2011, fraud and abuse were estimated to add $98 billion to federal spending for Medicare and Medicaid (Furrow, Greaney, Johnson, Stoltzfus Jost, & Schwartz, 2015). It is the dollar figures like those listed above, that have necessitated the need for the Office of Inspector General [OIG].

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.

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.

As research has shown, for providers and medical suppliers who submit bills for payment to Medicare, Medicaid, manage care organization or any form of a Medicare Advantage plan will eventually receive an overpayment of some type. (Scheininger & Samuel s, 2010). In some cases these overpayments may in fact be the result of an honest mistake. In other cases some of these overpayments may be intentional and the result of a health care fraud of scheme.

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

Healthcare services have been on the rise for over 10 years now. According to a 2012 consumer alert, the industry provided $2.26 trillion in payments for more than four billion health insurance benefit claims in the year 2011(Fraud in Health Care). The bulk of the claims and the mainstream of fraud and abuse stem from the Medicare system professionals, who are knowledgeable about the process and persuade new clients into handing over their pertinent information in hopes of deception and illegitimate claims. Multiple and double billing, fraudulent prescriptions, are some of the major flaws in this organization that has made the healthcare services industry curdle. (AGHAEGBUNA, 2011) This is a non-violet crime and is often committed by very

The most not unusual perpetrators of healthcare insurance fraud are fitness care providers. One reason for

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

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

Although Congress has used several anti-fraud measures to protect the federal government health care programs, the False Claims Act of 1986 has become the main weapon that government prosecutors use against perpetrators of health care fraud. Designed to prevent fraud and other abuses in federal government programs, the False Claims Act has been the primary statute the government has used in its fight against health care fraud. However, government prosecutors do not rely on one statute in their prosecution of alleged cases of health care fraud. Instead, they rely on a combination of statutes, but the False Claims Act has emerged as the main statutory weapon.

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

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 .

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.

(Jones and Jing) Though citizens might not see the effects of health care fraud directly, everyone is impacted in one way or another either through increased taxes, high insurance costs, or the inability to afford health care coverage. While we all hear about major frauds in the system, a majority of the frauds are small and usually go through undetected, unreported, or seriously underreported. (Sparrow) These small frauds add up to be a huge problem. There is a large spectrum of frauds in the health-care systems ranging from the theft of a wheelchair, to organized crime groups that steal patient information and bill for phantom services in multimillion-dollar schemes. (Jones and Jing) In many cases, the fraud is minor but all the small scams add up to an enormous loss to the public. For example, the frequent occurrences of forging of a doctor’s signature on a prescription accounts for billions of dollars lost each year. (Jones and Jing) One of the most common crimes involves billing for services that were never performed. This involves a health care provider submitting a false claim to be paid for a patient that was never treated or adding on services to a patient. For example a doctor may obtain names of other people such as a patients spouse or child who are covered by insurance and put in a claim for them as well as the actual patient. (FBI) Another common fraudulent activity involves upcoding of services. This is when a healthcare