Examples Of Medicaid Fraud

Medicaid fraud comes in many forms. A provider who bills Medicaid for services that he or she does not provide is committing fraud. Overstating the level of care provided to patients and altering patient records to conceal the deception is fraud. Recipients also commit fraud by failing to report or misrepresenting income, household members, residence, or private health insurance. Facilities have also been known to commit Medicaid fraud through false billing. The Medicare and Medicaid fraud and abuse statute provides that an individual who knowingly and willfully offers, pays, solicits, or receives any remuneration in exchange for referring an individual for the furnishing of any item or service

Medicaid is a public health insurance that is federally funded for those who do not have private health insurance (Families USA, 2014). In the U.S. one out of every five adults and one out of every three children use Medicaid (Families USA, 2014).

Medicaid is a joi8nt federal and state program. It provides health coverage to nearly 60 million Americans including children, pregnant women, seniors, and individuals with disabilities. As well as those people who are eligible to receive federally assisted income. Eligibility does however vary state to state.

Medicaid is a huge program that touches many lives but is nonetheless poorly understood by both the public and policymakers. Each state has the right to not participate in the Medicaid program, but Medicaid is one of the largest government insurance programs for individuals of all ages whose income and resources are insufficient to pay for health care.

The Medicare and Medicaid federal programs were put in place as a way to help the less fortunate. Individuals with severe disabilities or over the age of 65 qualify for Medicare. This program helps them with health coverage, so the disabled and elderly who have Medicare do not have to worry about their medical bills and not going to the hospital when they are sick. Medicaid is a similar program, however, it only applies to low income families who cannot provide for their children. Similar to Medicare, this program covers any health related problems and takes away the worry and troubles that come with hospital bills.

Medicaid is a social health care program that covers nearly 60 million Americans, including children, pregnant women, seniors, parents and individuals suffering with disabilities. Medicaid is the biggest source of funding for health related services and medical needs for the people with low income in the United States. This program is funded jointly by the state and federal level governments, but it is the state’s responsibility to manage this program. The Medicaid program is not a required program that states have to use, but all 50 states have implemented this program. With the introduction of the Affordable Care Act (ACA), and its passing in 2010, the ACA unveiled its plans to expand Medicaid eligibility to nearly all low-income adults as an addition to the other groups that fall into the Medicaid eligibility. The Medicaid program had “many gaps in coverage for adults” because it was only restricted to the low income individuals and other people with needs in their own specific category. In the past, the majority of the states who had adults that did not have children dependent on those parents were not eligible for Medicaid. These low income adults without dependent children would be without medical insurance assistance before the ACA was introduced. Medicaid is now available to all Americans under the age of 65 whose family income is at or below the federal poverty guideline of “133 percent or $14,484 for an individual and $29,726 for a family of four in 2011” (NSCL).

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.

Medicaid is health insurance that covers low income or no income people and families. There are some people that qualify for both Medicare and Medicaid. Due to the Medicaid Expansion (Obamacare), 26 states and the District of Columbia have eased some of the income requirements for Medicaid. Anyone below 138% of the federal poverty level is eligible

Following the death of a Medicaid recipient, the program not only can but must attempt to recover costs from the estate of the deceased. Medicaid's official site says:

Medicare and Medicaid fraud has some strengths as well as weaknesses. A strength that comes with healthcare fraud is The Affordable Care Act. This act helps to fight health care fraud, abuse and waste (Department of Human Services, 2014). Many laws have been implemented to help commit those people that have been committing Medicare and Medicaid fraud. Per the Center of Medicare and Medicaid services website “The Affordable Care Act increases the federal sentencing guidelines for health care fraud offenses by 20-50% for crimes that involve more than $1 million in losses, establishes penalties for obstructing a fraud investigation and makes it easier for the government to recapture any funds acquired through fraudulent practices” (Department

Medicaid is a federal and state program that helps with medical costs for some people who have a low income and limited resources. Medicaid is the largest source of funding for medical and health related issues in the United States. It provides medical care for nearly 60 million Americans (Medicaid History). Even though the program is joint between federal and state, the state decides how someone could be eligible for Medicaid.

A payor source, Medicare or Medicaid Medicaid is available to people with low incomes. These also include people who have reached a certain age, blind, disabled, and families who have dependent children. Poverty alone does not necessarily qualify someone for Medicaid; a patient has to fit into one of the seven categories which include assets, age, pregnancy, disability, blindness, income and resources, and one's status as a U.S. citizen or a lawfully admitted immigrant. Medicaid pays for some or all of the recipient's needs. The problem is that there is difficulty in describing 'low income' and many people who do deserve it are not on it.

The most common way individuals defraud the Medicaid system is by providing false information on their application or renewal applications, such as not reporting employment or assets. This includes falsifying supporting documents and not being truthful about the number of people in a household. People who obtain medications or home health equipment under false pretenses, for example, by lying to a physician, so he or she can sell the medication or equipment, is also committing fraud.

Medicaid is a social service program that offers health insurance to children and certain needy families. The problem that welfare recipients are having with Medicaid is that it is a challenge for them to get medication because they have to wait until a physician’s approval. Medicaid is intended for those that need medical attention and cannot pay for themselves. These recipients will push the limit just so they can get cash. Medicaid covered patients go around the streets and sell their prescription drugs to the pill buyers instead of them taking it. They go from doctor to doctor trying to get their medications because the recipients do not have to pay for any doctor visits nor do they have to pay for the expensive medications. They just go and sell them for cash or just trade them for the illicit drugs on the streets (Hast). Some addictive narcotics being sold are Oxycodone and Vicodin and can be highly expensive if you have no insurance. But

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