Health Care Fraud And Abuse

Health care fraud and abuse are one of the U.S healthcare system biggest problems, which affect everyone either directly or indirectly. Billions of dollars have been lost due to health care fraud and abuse. With a number of losses, this can lead to increase in health care costs and potential increased of coverage.

Another strength for the fight against fraud is the formation of the different teams, groups and organizations to help combat Medicare and Medicaid fraud. Among those that we started to alleviate the amount of fraud that has happened are; Office of Inspector General (OIG), the Healthcare Fraud Prevention and Enforcement Team (HEAT) and the General Services Administration (GSA). According to the Department of Health and Human Services “the OIG protects the integrity of HHS’ programs, including Medicare, and the health and welfare of its beneficiaries” (Department of Health and Human Services, 2014). The OIG carries out its duties through a nationwide network of audits, investigations, inspections, and other related functions. HEAT was established to build and strengthen existing programs combatting Medicare fraud while investing new resources and technology to prevent fraud and abuse. HEAT created the Stop Medicare Fraud website which provides information on how to stop and protect yourself and others from Medicare fraud as well as how to report fraud. The last system that was created was GSA which has strengthened the fight again fraud by converging several government groups into one group known as SAM or System for Award Management. According to the Department of Health “SAM includes information on entities debarred, suspended, proposed for debarment, excluded, or disqualified from receiving Federal contracts or certain subcontracts and from certain

Attempts to stop fraud were enhanced under Public Law 104-191, the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The purpose was to improve the Medicare program under title XVIII of the Social Security Act, the Medicaid program under title XIX of such Act, and the efficiency and effectiveness of the health care system. This public law encouraged the development of a health information system through standards and requirements for the electronic transmission of certain health information (aspe.hhs.go). The Act established a program to take action against fraud committed against public and private health plans. The legislation required the establishment of a national Health Care Fraud and Abuse Control Program (HCFAC), under the joint direction of the Attorney General and the Secretary of the Department of Health and Human Services (HHS) acting through the Department 's Inspector General (HHS.gov). The HCFAC program is designed to coordinate Federal, State and local law enforcement activities with respect to health care fraud and abuse. The Act requires HHS and Department of Justice (DOJ) detail in an Annual Report the amounts deposited and appropriated to the Medicare Trust Fund, and the source of such deposits. (HHS.gov) I will summarize the impact of these laws as it pertains to how they are impacting the healthcare delivery system. (HHS.gov)

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.

Collectively, the Department of Health and Human Services and the Department of Justice work to reduce healthcare fraud and investigate dishonest providers and suppliers. The Health Care Fraud Prevention and Enforcement Action Team recouped almost 3 billion in fraud, this year alone. Also, aggressive strategies exist to eliminate Medicare prescription fraud. Patients abusing or selling painkillers received by visiting several doctors and obtaining multiple prescriptions costs Medicare millions annually. Fraud affects everyone, preventing it requires government officials and citizens diligently working together.

The newspapers are flooded daily with articles about medicare frauds and abuse, consisting of corrupt physicians, pharmacists,executives and at times even the whole institution maybe involved in frauds worth millions of dollars . It is very essential to figure out the structural and functional loopholes which the allows such large amounts of frauds (Rivlin,

The way that the Medicare system is set up makes it easy for people to commit fraud. The program was originally set up on a honor system. This system

In reviewing the definitions of fraud and abuse by Medicare it may be hard for some people to

Now in 2015, healthcare fraud and abuse was getting to an all time high and now more situations were being committed such as phantom billing,false patient billing, upcoding and upbiling. Now several federal agencies had come together to eliminate several occurrences pertaining to this matter. The outcome to really crack down on this matter is when the U.S. government created the Health Care Fraud Prevention

According to the Department of Health and Human Services Centers for Medicare & Medicaid Services, these regulations stipulate the criminal, civil, and administrative alleviates the administration may enforce on persons or entities who perpetrate fraud and abuse in the Medicare Program, including Medicare Parts C & D and the Medicaid Program. Disregarding these regulations may stem in defaulting of claims, Civil Monetary Penalties (CMPs), sanction from all Federal healthcare curriculums,

Billions are lost each year in Medicaid fraud. Finding the right attorney to guide you through

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

Fraud and abuse in our healthcare system indicates a priority of wealth over health, puts patients at risk, and hinders our national interest of quality care. Medicaid and Medicare are especially vulnerable to fraud because eligible individuals may never see their bill for services; it goes directly to a fiscal intermediary (for Medicare) or a designated payer (for Medicaid), (Barton, 2007). In a report made by Jessica Zigmond, Aghaegbuna “Ike” Odelugo speculated on how and why the fraud occurs, "This is a nonviolent crime and is often committed by very educated people, including businesspeople, hospitals, doctors and administrators. It reaches across all ethnic and racial lines." He added that healthcare fraud often preys on what he called an unsuspecting victim base of Medicare recipients: elderly citizens looking for care and attention. The Priority Health Fraud & Abuse department is targeting specific practices in an effort to recover funds and end fraudulent

In this abstract, I will explain the specifics of my research and a detailed outline of my paper.

The reality is that healthcare fraud negatively impacts everyone in the nation. "Health care identity theft dominated all other crimes in the sector last year, according to Louis Saccoccio, executive director of the National Health Care Anti-Fraud Association (NHCAA), an advocacy group whose members include insurers, law enforcement and regulatory agencies" (Kavilanz, 2010). Groups of organized criminals are hacking into the digital databases of healthcare organizations so that they can take money from the Medicare system, which means that the government is actually the sole largest victim of health care fraud, according to the FBI (Kavilanz, 2010). The scope and vastness of such crimes truly impact everyone. The money that is stolen not only undermines the integrity of the healthcare system as whole, but is taken away from organizations and individuals who truly need it to help people fight fatal diseases, to help them overcome chronic conditions, to put them back to work and reunite them with their families. Fraudulent activity not only compromises the integrity of the entire healthcare system, but takes numerous victims, impairing the healthcare system from accomplishing the full extent of their goals.