Health Care Fraud Research Paper

Health matter, however, when the Act provide poor and/or low-income people with coverage that are as low as it can be with excellent benefits, people abuse it in way that sustain health problem. This result a serious health matter that can turn into a chronic illness or addiction, and cause complicated treatment that could cost a fortune to which is out of the Affordable Care Act coverage line. For example, a female driving a nice and luxury driving down the drive-thru to order her medicine with Medicaid coverage, what will the pharmacist think? Not only is this a fraud, but an abuse of the privilege received through the Affordable Care Act to obtain health insurance at a reasonably low price in order to maintain healthiness. This female have lied and continues to abuse this “authority” and purchase medicine that can worth hundreds of dollar.

Committing medical coding fraud or abuse is extremely detrimental to the healthcare industry. They both lead to higher healthcare costs and an increase in the cost needed for medical coverage. In addition, the increasing discovers of these acts are putting a very negative light on healthcare workers, including those who are not committing either act. With the medical world being so complex we often instill and great amount of trust in the persons taking care of medical billing and coding, this trust also makes committing fraud and abuse easier for dishonest people to take advantage of.

As you walk into your local grocery store you see tons of food products with health claims. A health claim is a statement about a food product and what it does for your health as part of a healthy diet. Health claims, mentions the physiological function like: “Calcium can build strong bones and teeth”. There are nutrition claims, ones that say: “Source of fiber, no added sugar, reduced in calories”. And lastly, disease risk factor of reduction claims. For example: “Diets high in calcium may reduce risk of osteoporosis” (Nutrition Content Claims and Health Claims.) But the real question: Is the food actually as healthy as the label claims to be?

Medicare and Medicaid have cause a great deal of damage to the American society. "Years of scandal have shown the waste, fraud and abuse that is rampant in Medicare and Medicaid." (Fallen Guardians of Justice: How the Supreme Court is

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

Medicare is national government run program that was developed in 1965. Medicare provides health insurance to Americans aged 65 and older who have worked and contributed to the program throughout their whole life by utilizing around 30 private insurance companies. The program also assists in providing benefits for younger people with disabilities. As well as offering Medicare in the United States a program called Medicaid is also available. Which is also a government run program, Medicaid is a state run program that provides hospital and medical coverage for people with low income (Medicare, 2015). With Medicaid being a state run program that allows each state to have different rules and regulations for who is and isn’t eligible as well as if they move across state lines. The programs listed above have helped many Americans over 65 and have a low income to be able to afford healthcare and receive the proper services for their healthcare concerns and issues. With any program and especially a government program there are going to be people who use and abuse the process which leads to Medicare and Medicaid fraud. There are many forms of fraud in Medicare and Medicaid such as billing for equipment or services that weren’t needed, falsifying health issues, dispensing generic prescriptions but billing for name brand. With there being so many types of fraud and investigations happening more and more due to the fraud that is occurring, people are finding more and more ways to

Over the years, the insurance companies have searched for ways to increase their profit margins at the expense of the hard working Americas striving to maintain their health at an affordable cost. The exchange appears to be working under the guise that they are trying to improve the quality of the health care delivered to patients. However, this does not seem genuine when closely examined. Inspection of performance of hospitals and providers is normal for certifying bodies such as the Joint Commissions and The Centers for Medicare & Medicaid Services (CMS), not insurance companies. Fraudulent claims normally investigated by insurance companies are normally caught and the company recovers some of that cost or denies the claim altogether if fraud is suspected. With this, it appears that the exchange is trying to branch off into a section of health care that it has not normally concerned itself with over the time that insurance companies have existed. It could be argued that the exchange may be

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

(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

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

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.

Where does the blame lie? I believe the blame lies with corporate greed because a corporation is defined as a profit making institution. Therefore if an individual is costing the company more money than what they are worth the company will terminate the employee. The insurance company is releasing medical information to the corporation on employees and their family members. Because of the insurance company doing so, the corporation terminated the employee and he was unable to get another job and to insure his family. Corporations have too much access to their employee’s medical situations.

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.

These crooks are the possible cause of ruining the reputation of the most trusted and appreciated professionals of our society – physicians. Healthcare fraud can be committed in a variety of ways, but three of the most widely used are described below. The first and most widely known, is billing services that were never endured by using general patient information. When giving personal information out, many hand it over to the front desk assistant at the local doctor. These appear to be people are some of the most known to scam the information and bill patient’s payments that never took place. Keep in mind that when handing over information, the handler is a trusted individual with a good reputation. On the other hand, many are scammed for the opposite; otherwise known as “upcoding,” where patients are billed more expensive services that were actually done. In fact, according to USA.gov a new study showed that 7 percent of identity fraud victims this year reported identity thieves stole their health insurance information, rising up from just 3 percent last year (Federal Bureau Investigation, 2010). This includes the latest scam, called “unbundling,” where scammers con bills and bill each step of a procedure as if it were a separate making the individual pay even more money, leaving devastating effects for the victim. All of which have a common goal of making taxpayers, insurance companies, and

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