Fraud In Health Care

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

Health care fraud and abuse is a significant contributor to high health care spending, resulting in the wasteful spending of health care dollars. The Federal Bureau of Investigation (FBI) and National Health Care Anti-Fraud Association (NHCAA) estimates that 3 to 10 percent of health care dollars are lost to fraud and abuse (Federal Bureau of Investigation, 2010). Fraud is the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the deception could result in some unauthorized benefit to themselves or some other person (Ryan, 2006). Bloomberg reports health care expenditures are rising faster than the rate of inflation and spending in the US has nearly doubled in the last decade and one-half of health care

Healthcare fraud and abuse are substantial influence related to increasing health care cost. In the face of the seriousness of fraud and abuse offenses, increasing numbers of healthcare providers is pursuing new and more lucrative procedures to build business relationships. In the aspect of following an unsafe practice in order to receive kickback is uncalled for and serves as further investigation is necessary. OIG ‘s mission is to protect the integrity of the HHS programs and the health and welfare of the people

According to the Federal Bureau of Investigation (FBI) “health care fraud costs the country an estimated $80 billion dollars a year” ("Health Care Fraud," n.d., p. 1). Because health care costs continue to rise more rapidly than the rate of inflation the threat of health care fraud continues to rise. The Affordable Health Care Act has put new policies in place to identify and stop health care fraud. The FBI along with other government, insurance, and public agencies have joined together to combat fraud at every level. New rules in identifying, investigating, and prosecuting fraud before payments are made to medical providers could save billions of

Medicare fraud is becoming a huge problem in today’s society. Medicare is a health insurance program for personnel paid by taxes the American population contributes to for personnel 65 years or older. When a health care provider, health suppliers, and private health companies deliberately bill Medicare for supplies or services that were not given is considered Medicare Fraud. To include, when a person uses another person’s Medicare card to receive health care for which the person does not qualify for. An individual, company, or a group can commit a Medicare fraud scheme.

Annually, America spends trillions of dollars on health care. To be more specific, roughly ten thousand U.S. dollars is used per person. However, health care fraud costs our nation about sixty-eight billion dollars every year. Being that, thousands of families are exploited and forced to undergo risky medical procedures. In addition, an individual's lawful insurance information and private medical record are used as false claims against them. As a result, it is worrisome seeing a family who could afford the means easily but still embezzles a member ID card that does not belong to them; while single mothers with several children are being rightful and properly paying for Medicaid or other programs while they have a low-income salary.

(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

The date of service should never be change. In order for the insurance to pay (if they accept to do it), billing should re-submit the claim with the information about that office visit. Medicare usually has a retroactive effective date for Part B premiums, which can be deducted from the lump sum of the SSDI. In some cases, then there may be Medicaid eligibility for a period of time and again, any services obtained during that time could be paid by Medicaid. If Nancy takes a chance and change the date and this action is made, it can lead to an investigation under Medicare Fraud. Medicare claims must be filed no later than 12 months after the date when the services were provided. If a claim isn't filed within this time limit, Medicare can't

Medicaid fraud is a concern in the medical world. The problem that medicaid faces is that people on that program are the most vulnerable of all. Many, do not understand what type of treatment they are getting, and don’t question whether they need the treatment or not. Furthermore, medicaid does not send the claims made by the provider to the client, or does not explain the services already paid. The case of “Davis Ethical Pharmacy,” proves the medicaid have a weak point: William Davis(the pharmacist involved in the medicaid fraud), took advantage of that weakness. He stole money from medicaid by “improperly billing,” not only he did it during store hours; but also after the drug store was supposed to be closed. As a patient, I would be concerned

Timely Home Health Services is under investigation for Medicare Fraud in the amount of over $13.4 million dollars. There are 4 defendants in this case; Okoroji, Ewah, Nwanguma, and Ogwuegbu. The allegations, that have been brought forth, are that between the years of 2007 and 2015, services for home health care were ordered with falsified documents. Once they sent the record to the provider, who ordered home health under the assumption the documents were correct, Timely sent in the claims for home health care for the patient. All 4 are indicted for conspiracy to commit healthcare fraud. Other counts are that Okoroji and Ewah are indicted on 5 counts, Ogwuegbu 4 counts, and Nwanguma 3 counts of healthcare fraud. The case was brought by

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

• promote OIG activities and accomplishments by reaching out to the public, media and other external entities

The False Claims Act if you are not aware “is a government act that is targeted at individuals and entities that defraud or try to defraud the federal government including any federal programs.”(Mattie, A., & Rosalyn Ben-Chitrit. (2009).) Health care fraud accounts for up to 10 percent of total health care expenditures and costs

Insurance companies and the federal government should pool resources using a percentage of profits to finance a task force to arrestively fight fraud. The penalty for fraud should be more stringent which will cause perpetrators to think twice before formulating a plan to commit fraud. The Affordable Health Care Act is the beginning of many programs established to fight against fraud. Health care fraud is a growing problem and should be taken more seriously by citizens of the United States. Physicians, health care workers, and patients are responsible for