Healthcare Fraud and Abuse

Health matter, however, when the Act provide poor and/or low-income people with coverage that are as low as it can be with excellent benefits, people abuse it in way that sustain health problem. This result a serious health matter that can turn into a chronic illness or addiction, and cause complicated treatment that could cost a fortune to which is out of the Affordable Care Act coverage line. For example, a female driving a nice and luxury driving down the drive-thru to order her medicine with Medicaid coverage, what will the pharmacist think? Not only is this a fraud, but an abuse of the privilege received through the Affordable Care Act to obtain health insurance at a reasonably low price in order to maintain healthiness. This female have lied and continues to abuse this “authority” and purchase medicine that can worth hundreds of dollar.

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

The purpose of this assignment is to review the factual content of and critically reflect upon the legal compliance considerations of eight major areas including, the Joint Commission, HIPAA/HITECH, Health Finances, Revenue Cycles, Medicare Recovery Audit Contractors, OIG work plan, OIG Corporate Integrity Agreement (CIA), the False Claims Act, and compliance and Provider Self Disclosure Protocol. These key elements have been provided by the GRC software Compliance 360 webpage.

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

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

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.

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]

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.

According to the new law the OIG’s effectiveness will be detecting fraud and abuse by expanding access to and uses of data for conducting oversight and law enforcement activities, including data-matching agreements between agencies. (Gatty, 2010). The HHA will establish procedures for screening providers and suppliers participating in Medicare, Medicaid and the Children’s Health Insurances program to prevent

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.

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

According to Paul E. Kalb MD, JD, these trends will likely continue”. Fraud and abuse will exist. Therefore, the strictest of fines and sentencing of imprisonment are the many consequences for anyone violating the law and it can include; civil monetary penalties, loss of licensing, loss of staffing privileges, and expulsion from participating in all federal health care programs. Under federal laws anyone that commits fraud at any degree especially fraud that results in any injury of any kind to a patient, fines and imprisonment doubles to twenty years in jail and if the fraud results in death of a patient they can and will be sentenced to life in a federal prison. The US Department of Justice also enforce federal criminal and civil statutes. The Department of Health and also the Human Services' Office of Inspector General can pursue administrative actions; and all state can pursued there own actions through their individual state laws. In addition, under the False Claims Act, acting in the name of the United States, private whistle-blowers may file suits against any physician that has committed these crimes. Enforcement of health care fraud and abuse laws has become increasingly self-satisfying and now affects many providers.