HHS OIG

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

In other words, it was not diligent auditors or highly mandated policies that reduced Medicaid fraud. In fact, the meticulous works of insurance companies are responsible. Today, physician offices place a patient’s photograph in the chart. Verifying the patient’s identity helps certify insurance claims are filed on behalf of the actual member. As a result, the state’s Medicaid program benefited from this much-needed change.

Medicare fraud is illegal and remedies are sought at both a civil and criminal level. If a provider, practice, or institution is found guilty of Medicare fraud, the consequences may include a loss of license, monetary penalties, and the inability to participate in Federal healthcare programs. The Office of Inspector General (OIG), which is a part of the U.S. Department of Health & Human Services, has the ability to exclude individuals who participate in Medicare fraud. The guilty party will be listed on a searchable database on the OIG website. The list is officially referred to as the List of

Some federal statutes address fraud in government health care programs, and many of these laws vary considerably (Krause 2004). Some of these laws specifically target health care fraud. Example of the laws that the government direct at inappropriate health care activities includes the “Medicare and Medicaid Anti-Kickback Statute and Ethics in Patient Referrals Act (EPRA).”

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

According to Roger Feldman, Blue Cross Professor of Health Insurance on the University of Minnesota, one of the main motives that medical fraud is this type of general exercise is that almost all of the parties concerned discover it favorable in some way. Many physicians see it as necessary to offer satisfactory care for their sufferers. Many sufferers, even though disapproving of the concept of fraud, are sometimes extra inclined to simply accept it when it impacts their own hospital treatment. Program administrators are regularly lenient on the problem of insurance fraud, as they want to maximize the services in their providers.[17]

Healthcare finances does not come without legal and regulatory issues. Issues in healthcare finances are false claims and whistleblower suits. The False Claims Act is a federal law that cover fraud in any federal funded program such as Medicare and Medicaid. This act covers knowing or conspiring to falsify any claim for payment by the federal government. In 2010 alone the government recovered over $7 billion in false claims, healthcare and pharmaceuticals made up 75% of total payment. And since then more than $130 million of claims has been settled.

The addition of the Affordable Care Act (ACA) has helped the CMS narrow down and shut down fraud. The government has new regulations of requirements for providers and what providers can participate under the ACA (Martin, 2015). There is additional screening for providers such as unscheduled visits, fingerprinting, background check, application fees, license checks, and most importantly they are now required face to face with patients before home health services. The government can suspend payments to providers under investigation. In addition, they can temporarily stop admission of new providers in the country when waste, fraud, and abuse are assumed

The Department of Health and Human Services Office of Inspector General (OIG) on April 20, 2015, working in partnership with the American Health Lawyers Association and the Association of Healthcare Internal Auditors, published Practical guidance for health care governing boards on compliance oversight. The guidance describes the OIG’s expectations of the compliance oversight and the roles governing boards should play in a healthcare organization.

Health insurance fraud is what drives up health insurance premium costs, wastes taxpayer’s money, but can also endanger beneficiaries or leave them uninsurable. In 2015, Medicare Strike Force reported over $700 million in false billing by doctors, nurses, other licenses medical professionals, laboratories, and individuals (FBI.gov). This is a staggering figure that is only getting worse. In this fictitious federal case I will be describing the criminal offender, the crime that was committed, the charge handed down by law enforcement, and the judicial process from the beginning of the criminal case to the sentencing of Dr. Richard Heartman, an internal medicine physician.

The Office of the Inspector General, for the U.S. Department of Health and Human Services is responsible for identifying and combating waste, fraud and abuse in more than one hundred programs such as Medicare. They perform extensive audits and investigations looking for any discrepancies.

As the Chief Nursing Officer of the state’s largest Obstetric Health Care Center, this author is responsible for complaints regarding fraudulent behavior in the center. The purpose of this report is to (1) evaluate how the Healthcare Qui tam affects health care organizations, (2) provide four examples of Qui Tam cases that exist in a variety of health care organizations, (3) devise a procedure for admission into a health care facility that upholds the law about the required number of Medicare and Medicaid referrals, (4) recommend a corporate integrity program that will

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

(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

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.