Healthcare Fraud and Abuse

Title II of HIPAA covers two main areas: preventing healthcare fraud and abuse, and a broad series of rules under the framework of administrative simplification. The first area is not of significant interest to most healthcare workers. It defines numerous offenses relating to healthcare, and authorizes several programs to attempt to find and control fraud and abuse. Nurses should be aware of the proper procedures for reporting fraud and abuse at their facility. The second portion of Title II—administrative simplification—however, contains five separate rules, most of which have already had a significant impact on virtually everyone working in American health care, including all those working in any way with health information concerning

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

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

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

Public healthcare applications inclusive of Medicare and Medicaid are particularly conducive to fraudulent activities, as they're frequently run on a price-for-carrier shape.[20] Physicians use several fraudulent techniques to reap this give up. These can consist of “up-coding” or “upgrading,” which involve billing for more high-priced treatments than the ones surely provided; presenting, and in the end billing for, remedies that aren't medically essential; scheduling greater visits for sufferers; referring patients to different physicians when no in addition treatment is really important; "phantom billing," or billing for services now not rendered; and “ganging,” or billing for services to own family members or other people who are accompanying the affected person however who did now not in my view receive any offerings.[20]

Medical fraud and abuse is a huge contributing factor in the rise of healthcare costs in the United States. Although there are many definitions of fraud and abuse, according to Cigna and HIPPA, Medical fraud is false representation of a substance, device or therapeutic system as being beneficial in treating a medical condition, diagnosing a disease, or maintaining a state of health. Medical Abuse is defined as any action that intentionally harms or injures another person. It also involves actions that are inconsistent with accepted, sound medical, business or fiscal practices. Abuse directly or indirectly results in unnecessary costs to medical programs through improper payments. Insurance fraud occurs when companies

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.

Now in 2015, healthcare fraud and abuse was getting to an all time high and now more situations were being committed such as phantom billing,false patient billing, upcoding and upbiling. Now several federal agencies had come together to eliminate several occurrences pertaining to this matter. The outcome to really crack down on this matter is when the U.S. government created the Health Care Fraud Prevention

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.

People can be affected by healthcare fraud and abuse directly and indirectly. Fraud is defined as an intentional deception, false statement or misrepresentation made by a person with the knowledge that the deception could result in unauthorized benefit to oneself or another person. It includes any act that constitutes fraud under applicable federal or state law. Abuse is defined as practices that are inconsistent with professional standards of care; medical necessity; or sound fiscal, business, or medical practices. Intent is the key distinction between Fraud and Abuse. An

Another effective way of controlling healthcare fraud and abuse is through reinforcement of federal penalties, enforced by the department of Health and Human Services. For example, in the year 2011, the US department of Health and Human Services committed approximately $248 million in the fight against fraud and abuse. This extraordinary effort resulted in a significant increase in the number of cases prosecuted, amount of money recovered, and the dollar amount of claims filed. The federal government can assist healthcare overall fight the abuse and fraud by being assiduous in prosecuting the providers, the healthcare organizations, and individuals who commit fraud and abuse in an organized and systematic manner, not sparing anyone, because

Healthcare reform has been challenge for many people of the great United States of America. There are sick people who are dependent on their healthcare benefits to aid in the recovery of an illness or just remain in the most stable condition possible. One of the hot topic issues that exists within healthcare reform is the cost of healthcare which includes insurance, medication, and other expensive, but necessary parts. The Trump administration has chosen another path for underinsured, low to average income citizens of the U.S. The ethical issues created by latest healthcare reform are an extension

The reality is that healthcare fraud negatively impacts everyone in the nation. "Health care identity theft dominated all other crimes in the sector last year, according to Louis Saccoccio, executive director of the National Health Care Anti-Fraud Association (NHCAA), an advocacy group whose members include insurers, law enforcement and regulatory agencies" (Kavilanz, 2010). Groups of organized criminals are hacking into the digital databases of healthcare organizations so that they can take money from the Medicare system, which means that the government is actually the sole largest victim of health care fraud, according to the FBI (Kavilanz, 2010). The scope and vastness of such crimes truly impact everyone. The money that is stolen not only undermines the integrity of the healthcare system as whole, but is taken away from organizations and individuals who truly need it to help people fight fatal diseases, to help them overcome chronic conditions, to put them back to work and reunite them with their families. Fraudulent activity not only compromises the integrity of the entire healthcare system, but takes numerous victims, impairing the healthcare system from accomplishing the full extent of their goals.

Healthcare fraud and abuse has become a major issue in the medical industry, it is estimated that billions of dollars are lost annually due to healthcare fraud. Healthcare fraud can occur in many forms for instance, billing for services that weren't provided, or perhaps a duplicate submission of a claim for the same service. "Upcoding" is a term used when providers charge for a more complex or more expensive service than that which is actually provided. Also billing for a covered service when the service actually provided was not covered. Those are some examples of how providers commit healthcare fraud. Members also commit healthcare fraud when they use a member id that does not actually belong to them. Also when they add someone to a policy

According to the legal dictionary, "health care fraud is a type of fraud that involves the use of our health care systems by an individual, medical provider, insurance company in a dishonest manner to profit from it" (Health Fraud). Fraud includes single groups of people, employers and government supplying false information, claim services or documentation that was never provided, changing patient or doctors signatures or changing medical records to establish misrepresented services, and even submitting a request twice. While health care fraud may not be a label as everyday crime people and business touches, hurt and even destroyed by this act. This crime has caused an insurance premium to skyrocket for individuals, small companies, and corporations