Healthcare Fraud And Abuse In The United States

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

When providers or patients submit false or misleading information intentionally to a health plan, this is fraud. Some examples of healthcare fraud and abuse include filing claims for services or medications not actually performed or obtained, billing for services for non-covered items using codes for billable services or items, altering medical records, waiving co-pays and deductibles, up coding and unbundling, using someone’s insurance card, billing Medicare patients at a higher fee than non-Medicare patients, and accepting kickbacks for referring patients, to name just a few. Fraud can be committed by hospitals, medical providers, laboratories, pharmacists, billing services, medical equipment suppliers, and even patients. Patients can protect themselves from healthcare fraud and abuse by knowing their healthcare benefits, reviewing the explanation of benefits, asking the doctor to explain the service that was given, report discrepancies, protect insurance cards and member identification numbers, beware of free services, report copayment and deductibles being waived, and never sign blank insurance forms.

The goal of this deception is to obtain a federal healthcare payment that would not otherwise exist. The provider, practice, or institution may falsely claim to have provided a service or used supplies for a patient when in reality neither the service nor the supplies were used. A secondary way to commit Medicare fraud involves referrals. If one solicits, pays, or accepts money to encourage referrals because the services are reimbursed by Federal healthcare programs, they are participating in Medicare fraud. This type of fraud is addressed in the Anti-Kickback Statute. Lastly, Medicare fraud occurs when the complexity of services are overstated and billed at a higher than necessary rate. This action violates the False Claims Act which protects the government from being excessively charged for goods and services.

Medicare and Medicaid fraud has some strengths as well as weaknesses. A strength that comes with healthcare fraud is The Affordable Care Act. This act helps to fight health care fraud, abuse and waste (Department of Human Services, 2014). Many laws have been implemented to help commit those people that have been committing Medicare and Medicaid fraud. Per the Center of Medicare and Medicaid services website “The Affordable Care Act increases the federal sentencing guidelines for health care fraud offenses by 20-50% for crimes that involve more than $1 million in losses, establishes penalties for obstructing a fraud investigation and makes it easier for the government to recapture any funds acquired through fraudulent practices” (Department

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.

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

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.

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.

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

Fraud is a serious crime that should concern all parties of the U.S. health care system and is a costly reality that the government cannot overlook. While not all fraud can be prevented, by learning about the many different types of fraud, patients can be educated on how to protect themselves from fraud. If we use government programs to inform the public that they can be targeted, the dollar amount for these cases for fraud can be reduced. An informed public and a properly funded FBI will go a long ways in the overall crackdown of health care fraud.

New government statistics show federal health care fraud prosecutions in the first eight months of 2011 are on pace to rise 85% over last year due in large part to ramped-up enforcement efforts under the Obama administration. The statistics, released by the non-partisan Transactional Records Access Clearinghouse, show 903 prosecutions so far this year. That's a 24% increase over the total for all of fiscal year 2010, when 731 people were prosecuted for health fraud through federal agencies across the country. Prosecutions have gone up 71% from five years ago, according to TRAC. (Kelly Kennedy

Annually, America spends trillions of dollars on health care. To be more specific, roughly ten thousand U.S. dollars is used per person. However, health care fraud costs our nation about sixty-eight billion dollars every year. Being that, thousands of families are exploited and forced to undergo risky medical procedures. In addition, an individual's lawful insurance information and private medical record are used as false claims against them. As a result, it is worrisome seeing a family who could afford the means easily but still embezzles a member ID card that does not belong to them; while single mothers with several children are being rightful and properly paying for Medicaid or other programs while they have a low-income salary.

In a scheme based in New Jersey and set to spread to eleven other states, Sheila Kahl, admitted to participating is a $1 Million Dollar Medicare fraud scheme. Along with her accomplice, Seth Rehfuss, convinced senior citizens to get genetic testic. The two fraudsters received commissions based off of the quantity of test that were ordered. To escalate matters, the two fraudsters used craigslist to locate healthcare providers that would work with them. Additionally, the two fraudsters also paid kickbacks to the healthcare providers that signed off on the testing for the senior citizens. (Pressofatlanticcity.com," n.d.)

The table below sets forth HCFAC funding, by agency, for health care fraud and abuse control activities in FY 2014, including sequester reductions. The FBI also receives a stipulated amount of HIPAA funding for use in support of the Fraud and Abuse Control Program, which is shown below. Separately, CMS receives additional Mandatory Resources under the Medicare Integrity Program (section 1817(k)(4) of the Social Security Act). The inclusion of the activities supported with these funds is not required in this report, and this information is included for informational purposes.

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.