Essay On Health Care 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

Health care has gone through a huge change since the advent of technology. This resulted in a corresponding high health cost. A third party, the insurer stepped in to help customers; patients overcome the high cost of health care. This meant measuring cost against service, demanding the details of services rendered to the patient. This in a way a patient’s information is given out to the insurer as per legal contracts signed in the agreement. This poses deep ethical challenges because even beyond management, other workers access the information when making inputs. Patients strictly have rights to keep secrete their medical problems between them and their health providers. The necessity to get help to buy health care however has made it impossible for patients to have their autonomy in that regard.

In the health care business, there are certain standards and laws that have been put in place to protect our patients and their personal health information. When a health care facility fails to protect their patient’s confidential information, the US Government may get involved and facilities may be forced to pay huge sums of money in fines, and risk damaging their reputation.

On November 21, 2013, Theanna Khou pleaded guilty to dispensing and selling OxyContin from his Huntington Pharmacy without medical necessity from fraudulent prescriptions issued by a clinic (" Health care fraud investigations," 2014). Khou billed Medicare for filling prescriptions that patients never received. This story is becoming a norm for the health care industry, because the growing financial prosperity of the health industry. Corruption and crime is changing, turning from drug dealing to a safer haven that has less legal management, organization, and more wherewithal the business of health care fraud.

Physician and pain clinic owner Paramjit Singh Ajrawat, of Potomac, Maryland has been ordered to

Although the discussion focuses on the risk manager, most large health care organizations employ a team of individuals to reduce the risks of loss and increase patient safety from both a proactive and reactive stance. The health care environment is constantly evolving, but nothing has made change as pervasive as the Patient Protection and Affordable Care Act (PPACA) and the regulatory and compliance mandates contained within its wording. For instance, maintaining confidentiality of patient information, a key function of risk management, is now more difficult with the rise of cybercrime of medical information. According to Finkle (2014), the Federal Bureau of Investigation warns health care providers there is high demand for medical information by criminals to commit both impersonation crimes and financial fraud. These concerns were unheard of not long ago. Confidentiality and protection of patient information is only

Fraud and abuse encompasses the actions of fraud, abuse, and waste in the health care system (McWay, 2014). It is a nationwide problem that affects all of us and can be committed by anyone. Schemes can be committed by a single person or a by an institution or group. The National Health Care Anti-Fraud Association (NHCAA) estimates that

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

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.

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.

It is very imperative for all members of the medical team to know the laws in there profession, and that there is consequences if the laws are broken. As a Medical Assistant, it is their duty to protect the patients privacy, and confidentiality. Also as Medical assistant,we cannot diagnose or treat any illness to a patient, or even prescribe medicines over the phone, even if they are over the counter. A Medical assistant is only allowed to educate the patients about there illness, and let the physician diagnose or treat their patients. There are many laws the pertain to the medical field, and many consequences if the laws are broken. Some of the consequences could result in loosing your licenses, suspension,fired from your job, large fines,or

The typically overlooked crime of healthcare fraud has resulted in a significant monetary loss on the part of the American public paying into government run medical programs, as well as private insurance company programs. Historically, we have seen that in any instance where money is involved people have found ways to or at least have attempted to obtain it illegally. Some do it through overt acts of violence such as a robbery. Others choose more covert ways of illegally obtaining money. This is usually conducted through fraudulent activities. This is the nature of white-collar crime. There is no force or violence involved but it is still illegal. (SSA) Obviously, when such a large amount of money is involved there is

This booklet is designed to serve as a guidance to concepts of fraud and abuse laws which affect the coding, claims management, charge master and bill reconciliation. It is important to understand the laws as a variety of health care providers’ payment and arrangement activities are prone to fraud which eventually result in criminal penalties and unethical behaviors in health services. To evade associated liabilities, employees should understand the fraud and abuse laws and compliance policies.

Healthcare fraud is costly for everybody, as it harms the reputation of the institution or physician committing it, and financially damages the patient being affected.By definition fraud may be defined as intentionally employing surprise, trickery, cunning, deception and unfair ways by which one party cheats another party out of financial resources. In order to educate a healthcare manager regarding fraud , many aspects of fraud must be assessed. This includes the types of fraud, the consequences that come with fraud,the individual(s) committing them, techniques to prevent fraud, and why the healthcare industry is vulnerable to fraud.