Healthcare Fraud

Federal or state authorities may investigate allegations of fraud depending on where the fraud was reported, the laws broken, and the amount of money involved. The strictness of penalties levied by state governments varies from state to state. Federal laws such as The False Claims Act, Anti-Kickback Statute, and Social Security Act are laws that address fraud and abuse. Title XI of the Social Security Act contains Medicaid program-related anti-fraud provisions, which impose civil penalties, criminal penalties, and exclusions from federal health care programs on persons who engage in certain types of misconduct (Staman, 2010). Under federal regulations, providers convicted of fraud are excluded for a minimum of five years from receiving funds from any federally

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

The increase of expenses - As politicians continue their dissension amongst each other, the situation is worsening in our healthcare system. According to the World Health Organization, to achieve universal health coverage, countries need a financial system that enables people access to all types of health services without incurring financial hardship (Carrin, Mathauer, Xu, & Evans, 2011). This idea would be the foundation of innovative ideas that the U.S. could reform its healthcare system, but too many ideas are sabotaging any valid efforts. In the mean time, the U.S. healthcare system continues to deal with issues such as the increasing uninsured Americans (over 49 million), expensive administrative procedures and the inability to measure the accuracy of quality of care, access of care, and the increasing healthcare spending and financing that limit our ability to efficient utilize resources.

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

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

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.

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

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 and waste of resources allocated for Medicare pose major risks to the program. Medicare is very vulnerable to a number of frauds majorly due to the fact that the program is hardly audited. Medicare scams occur in various ways that include phantom billing where healthcare providers demand money from Medicare for services not offered. The other form of fraud happens in the shape of patient billing where the patients collude with scammers to claim for kickbacks for false medical treatments. The last type of fraud is the upcoding scheme and unbundling, where bills are inflated by claiming that a patient needs more valuable services or procedures than the existing. The government has been sensitizing the general public on the need to avoid such frauds by not disclosing their Medicare card details to

(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.

I believe health care fraud and abuse has definitely decreased since technology has changed and upgraded. Not only has it prevented fraud and abuse but it has also protected many people's healthcare information a lot more confidential. Most people actually trust technology more than actual files that are kept in a healthcare facility. Technology is always going to change and upgrade because it is all about trial and error. If something is working, in order to prevent or decrease the amount of fraud and abuse that people have been doing you need to test out the technology to know if it works or not. And by the looks of it, it seems like all the fraud and abuse has decreased a lot more than before the technology was started.

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