Healthsouth Fraud Essay

Committing medical coding fraud or abuse is extremely detrimental to the healthcare industry. They both lead to higher healthcare costs and an increase in the cost needed for medical coverage. In addition, the increasing discovers of these acts are putting a very negative light on healthcare workers, including those who are not committing either act. With the medical world being so complex we often instill and great amount of trust in the persons taking care of medical billing and coding, this trust also makes committing fraud and abuse easier for dishonest people to take advantage of.

1. What are several red flags that E&Y either was or should have been aware of in the audit of HealthSouth?

The story of HealthSouth begins with two of the most well know founders. Richard Scrushy was a bold, charismatic man of middle-class beginnings. He would rise from a mason to one of the highest earning CEO’s in the country due mainly to his ability to drive, charm, and manipulate those around him. Driven by the desire to attain wealth and status Scrushy was hired in at LifeMark where he rose through the ranks as a result of his unbridled competitive nature and workaholic tendencies.

HealthSouth is one of the nation’s largest healthcare providers specializing in rehabilitation. HealthSouth was founded by Richard M. Scrushy in 1984 and went public in 1986. Scrushy served as its Chairman of the Board from 1994 to 2002. The company was incorporated in January 1984 as Amcare Inc. before its name was changed to HealthSouth Rehabilitation Corporation in May 1985. In January of 2003, Mr. Scrushy reassumed the position of CEO.

A forensic audit conducted by PricewaterhouseCoopers concluded that HealthSouth Corporation 's cumulative earnings were overstated by anywhere from $3.8 billion to $4.6 billion, according to a January 2004 report issued by the scandal-ridden health-care concern. HealthSouth acknowledged that the forensic audit discovered at least another $1.3 billion dollars in suspect financial reporting in addition to the previously estimated $2.5 billion. The scandal 's postmortem report

Richard M. Scrushy is one the founder of HealthSouth in 1984. And he also is the CEO of HealthSouth. At the beginning with his friend in Amcare Company, he use a million dollars investment by Citicorp Venture Capital to founded HealthSouth. Two years later, Richard made HealthSouth become a listed company. In 1987 HealthSouth has expanded to two new areas, which is worker’s compensation and sports medicine. Thus it makes HealthSouth earned a hundred million dollars. By 1988, HealthSouth has operated a network of 21 outpatient facilities, 11 inpatient facilities, and seven rehabilitation equipment centers in 15 states, it has became the leader of rehabilitation industry in the U.S(James Press, 2000).

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.

Managed care dominates health care in the United States. It is any health care delivery system that combines the functions of health insurance and the actual delivery of care, where costs and utilization of services are controlled by methods such as gatekeeping, case management, and utilization review. Different types of managed care plans came into development by three major factors. These factors include choice of providers, different ways of arranging the delivery of services, and payment and risk sharing. Types of managed care organizations include Health Maintenance Organizations (HMOs) which consist of five common models that differ according to how the HMO is related to the participating physicians, Preferred Provider Organizations

Fraudulent prescriptions are also on the rise. Physicians are writing illegal prescriptions that are billed for a claim for reimbursement, but have yet to see a bill of rendered services that called for the actual prescription. This often ends up happening to a patient who has little or no medical issues and has never been seen before. The provider who receives the forged prescription profits an anticipated amount of 15% to $20% in profits. (AGHAEGBUNA ,2011). There are four types of fraud that healthcare providers’ organization face. Patient fraud, provider employee fraud, provider billing fraud and payer fraud, even though providers need to receive payment for their service they should be more preventative action in place to ensure that these fraudulent activities can be detected.

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

Texas has the largest uninsured population with an estimated 6.2 million uninsured citizens within its stateliness, approximately a quarter of the statewide population (Rapoport, 2012). In 2012, then governor, Rick Perry decided that Texas would not expand Medicaid under the Affordable Care Act (ACA). This decision led to much debate over whether or not Perry made the right decision to leave upwards of a million Texans, who did not receive insurance subsidies and did not qualify for Medicaid, uninsured. These Texans fell under what many politicians refer to as the “coverage gap.” Texas decided not to expand Medicaid under the Affordable Care Act because of the effects it would have on hospitals, financial reasons, and increased number of

This study sought to answer three research questions. Although the questions have been presented in previous chapters, they are worth presenting again.

Throughout the last half of the 20th century, employers have acted on their own to regulate health costs by requiring employees to join health maintenance organizations (HMOs). More than 100 million Americans are under managed care. However, many patients and doctors complain that HMOs impose too many regulations and sacrifice healthcare quality. HMOs are undergoing a high level of scrutiny due to criticisms that the network is controlling and jeopardizing the healthcare system of the nation.

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