Health Care Fraud Summary

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 the news recent was the Miami physician pleads guilty for role in $20 Million health care fraud scheme (Justice. Gov). The FBI and HHS-OIG investigated the case, which was brought as part of the Medicare Fraud Strike Force, under the supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office of the Southern District of Florida (Justice.

As anyone can see, health care fraud is a huge issue in the United States and with the upcoming nationalized health care system finally going into effect this year, more opportunities

It is easy to see how fraudulent medical billing is having a major impact on the Unites States and the citizens of this country who rely on it on a daily basis. We often hear through the various new sources in this country, on the internet or out of the mouths of politicians and experts in the healthcare field about the failing healthcare system in this country. We often hear many different opinions on what needs to be done to fix our healthcare problem within this country and fix what looks to be a very broken system at this point. No matter what the solution to our poor healthcare system is one thing that is very clear is that healthcare fraud and abuse is playing a major role in the depletion of money in this country and the rise in healthcare costs for the citizens of this country.

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.

Perhaps the finest total dollar quantity of fraud is devoted via the medical health insurance companies themselves. There are severa research and articles detailing examples of insurance companies deliberately not paying claims and deleting them from their structures,[21] denying and cancelling coverage, and the blatant underpayment to hospitals and physicians beneath what are normal costs for care they provide.[22] Although tough to acquire the records, this fraud via coverage agencies may be anticipated through comparing revenues from premium bills and prices on health

Medicaid fraud is illegal, but it is still big business. According to the Office Of Management and Budget, Medicare made nearly $47.8 billion improper payments in 2010. This is nearly 10 percent of the $528 billion spent on Medicare. The United States cannot afford to keep dealing with this type of fraud.

At least 3% of that spending (68 billion) is lost to fraud each year. Raising health care costs for everyone.

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

So, what is healthcare fraud and abuse is, you may ask? When talking about healthcare fraud and abuse, we are talking about 2 major statutes in the healthcare industry, Physician Self-Referral (Stark) Law and AKS (Anti-Kickback Statutes). These laws apply to many practices and procedures within organizations and can be manipulated to benefit an organization financially. The Physician Self-Referral Law prohibits entities from presenting a claim to anyone for healthcare services for a service not rendered and it also prohibits a physician for creating a referral for services that are designated but are not rendered. AKS prohibits anyone from offering a kickback, paying a kickback, or receiving a kickback in return for the delivery of health care services. However, the AKS encourages referrals based on monetary rewards to the primary source rather than

Healthcare fraud and abuse in 2014 was costing Americans billions of dollars each year. Healthcare fraud intentions was to deceive a company into paying for services that in most case was not provided or should not been provided. Majority of the ones breaking the law are as follows physicians, patients,laboratories and some hospitals.

Federal directives which oversee Medicare fraud and abuse incorporate all the following: 1) False Claims Act (FCA) 2) Anti-Kickback Statute (AKS) 3) Physician Self-Referral Law (Stark Law) 4) Social Security Act 5) United States Criminal Code.

What is healthcare fraud? Healthcare fraud is a criminal behavior, in which a person files a false claim, with the purpose of reimbursement. Healthcare abuse is similar, but focuses more on practices that do not match up with accepted solid financial, business, or medical practices, thus resulting in an avoidable cost or repayment for services that are not needed, or that fail to meet professionally familiar values for healthcare (Johns Hopkins, n.d.). While these both may have very different definitions, they are fall under the category of healthcare fraud and are both punishable by law when convicted. Healthcare fraud may be something as simple as a doctor over billing the insurance for only a few dollars, all the way on up to

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

The largest and most vulnerable health care program that is exploited by Fraudulent deceptions, that expand across the federal, state, and local agencies is Medicaid. The multiple insurance companies encounter fraud schemes that cross state lines and enforcement jurisdictions, that involves serval health care sectors that probably experience challenging priorities during their investigations, prosecutions, and when they are enforcing compliance (GAO/T, 1999). The joint efforts of coordinating with the multiple insurers, has proven that experience has been the best way for all companies, that are invested in preventive strategies, and who are applying acceptable amounts of resources to fraud control essential components, that have a well-organized program with integrity strategy.