Healthcare Fraud : The Affordable Care Act

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

On November 21, 2013, Theanna Khou pleaded guilty to dispensing and selling OxyContin from his Huntington Pharmacy without medical necessity from fraudulent prescriptions issued by a clinic (" Health care fraud investigations," 2014). Khou billed Medicare for filling prescriptions that patients never received. This story is becoming a norm for the health care industry, because the growing financial prosperity of the health industry. Corruption and crime is changing, turning from drug dealing to a safer haven that has less legal management, organization, and more wherewithal the business of health care fraud.

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 other words, it was not diligent auditors or highly mandated policies that reduced Medicaid fraud. In fact, the meticulous works of insurance companies are responsible. Today, physician offices place a patient’s photograph in the chart. Verifying the patient’s identity helps certify insurance claims are filed on behalf of the actual member. As a result, the state’s Medicaid program benefited from this much-needed change.

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

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.

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

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.

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

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

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.

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.

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

The aim of this report is try to evaluate how the insurance industry has developed in Brazil since it began its operation in 1808, operating in the begging only with maritime insurance through company named Boa Fé. During that time Brazil was still a colony of Portugal and Boa Fé Company had the role to insure ships transporting valuable goods