Health Insurance Fraud Essay

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

Healthcare fraud and abuse are substantial influence related to increasing health care cost. In the face of the seriousness of fraud and abuse offenses, increasing numbers of healthcare providers is pursuing new and more lucrative procedures to build business relationships. In the aspect of following an unsafe practice in order to receive kickback is uncalled for and serves as further investigation is necessary. OIG ‘s mission is to protect the integrity of the HHS programs and the health and welfare of the people

Most health care providers deliver quality medical care to their patients. However, there are some providers that commit health care fraud and abuse. Health care fraud costs an estimated $68 billion to $226 billion annually (Health Care Fraud and Abuse, 2016). It is a crime under federal and state laws and violations can result in loss of health care coverage, fines, and even jail time.

Some estimate that the federal government loses 30 percent of every dollar it spends on medical claims, due to medical billing mistakes and fraud. With so many loopholes and regulations surrounding Medicare, it is impossible for one person to know every nuance. However, constant diligence and ethical practices are a cornerstone of catching and preventing medical billing mistakes.

The Government Accountability Office has indicated that Medicare Advantage plans frequently bill us due to inflated risk scores.  At least six whistle-blowers have sued health plans because they said that the plans attempted to boost their profits by tampering with the risk scores.  Among the first to settle was The Sewell

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

Healthcare fraud and abuse are different terms that describe different types of deceitful acts done by healthcare professionals or by solo individuals. Fraudulent medical billing is defined as knowingly submitting false statements or making misrepresentations of facts or false documentation to obtain a health care payment. These payments for which no entitlement would otherwise exist, knowingly soliciting, paying, and/or accepting compensation to encourage or reward referrals for items or services reimbursed by federal health care programs and making prohibited referrals for certain designated health services. Fraud healthcare schemes include

fraud risk exclusion from participation in Federal health care programs and the loss of their

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

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.

What is Medicare fraud? ("F&A," 2011, p. 1) states “Medicare fraud happens when Medicare is billed for services or supplies you never got. Medicare fraud costs Medicare a lot of money each year.” What is Medicare abuse? ("F&A," 2011, p. 1) defines this as “Abuse occurs when doctors or suppliers don’t follow good medical practices, resulting in unnecessary costs to Medicare, improper payment, or services that aren’t medically necessary.”

(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

Dr. Ofer Zur (2016) reported that some mental heath providers have submitted inaccurate insurance bills to get paid more units for services they did not render. For that reason these same therapists may have over- diagnose youth with disorders in order to defraud the insurance companies. Dr. Zuf (2016) also states that these therapists have included patients in their illegal activities by promising them that they receive larger reimbursement check from their insurance company(para.1). According to research “false billing practice has become very common, some therapists are not even aware that they are involved in what some people call "theft by deception”( Zur,2016.para,1).

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