Medicaid Fraud Research Paper

Fraud is defined as the intentional deception or misrepresentation of facts that can result in unauthorized benefit or payment. Abuse is

Medicaid fraud comes in many forms. A provider who bills Medicaid for services that he or she does not provide is committing fraud. Overstating the level of care provided to patients and altering patient records to conceal the deception is fraud. Recipients also commit fraud by failing to report or misrepresenting income, household members, residence, or private health insurance. Facilities have also been known to commit Medicaid fraud through false billing. The Medicare and Medicaid fraud and abuse statute provides that an individual who knowingly and willfully offers, pays, solicits, or receives any remuneration in exchange for referring an individual for the furnishing of any item or service

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.

Those who utilize the Medicaid system range from low income families to the over 65 age group. Within this population is also those who are disabled due to physical or mental problems. This is among the sickliest of our American population. A paper based on a study in Oregon stated that “Medicaid significantly increased the probability of being diagnosed with diabetes, and being on diabetes medication as well as high blood pressure and high cholesterol.”(Baicker et al., 2013, p. 1715). Much of this is due to the struggle that the Medicaid beneficiary has

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.

This paper will discuss the early years and failed efforts that transformed the Medicaid program into what is seen today. A comparison between Medicaid and Medicare will be brief but is necessary because there are significant and critical differences between these government-funded insurance options. The substantial growth of Medicaid expenditures and beneficiaries are important and these trends will be looked at in detail. There have been provisions related to the unanticipated expansion of this program which will be reviewed. Attempts to expand Medicaid eligibility further need to be addressed (example: Patient Protection and Affordable Care Act). Stigmas that are associated with receiving Medicaid will be reviewed. I will share my

Medicaid is a medical assistance program for low-income Americans. It is funded partially by the federal government and partially by the state and local governments. The federal government requires that certain services be provided and sets specific eligibility requirements. Medicaid covers the following benefits required by the federal government; early and periodic screening, diagnosis, and treatment services, rural health clinic services, family planning services, SNF and home health services for persons over 21 years old, physicians’ services, laboratory and x-ray services, outpatient hospital care, and inpatient hospital care. Because Medicaid is also partially run by the state and local government individual states sometimes cover services

Some federal statutes address fraud in government health care programs, and many of these laws vary considerably (Krause 2004). Some of these laws specifically target health care fraud. Example of the laws that the government direct at inappropriate health care activities includes the “Medicare and Medicaid Anti-Kickback Statute and Ethics in Patient Referrals Act (EPRA).”

Medicaid has become an essential program for many, proving comprehensive inpatient and outpatient health care coverage, including many services and expenses Medicaid does not cover, especially, prescription drugs, diagnostic and preventive care, and eyeglasses. Medicaid can also help supplement Medicaid deductibles and premiums and pay a 20% portion of uncovered charges in some cases (Hansen, 2012). The program supports the country's most vulnerable and frail including children, those requiring long-term care services for chronic mental illness and retardation and those needing AIDs therapy (Goodman, 1991). These are enormous societal needs that may not be met without the assistance of Medicaid.

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

Common fraudulent practices include billing for services never received, upcoding or unbundling of services, and mislabeling. Billing dishonest services occurs anytime a healthcare provider charges Medicare for a service the patient never received or billing for a more expensive service than performed. Upcoding and unbundling, two examples of billing for a more expensive service demonstrate this fraudulent practice. Simply put, upcoding occurs by billing more expensive codes than the services performed, while unbundling refers to a “bundled” service broken down or unbundled, allowing procedures billed separately to obtain a higher reimbursement than customary. Mislabeling, the practice of substituting non-covered services or products with services or products covered under Medicare guidelines also constitutes fraud. For example, a home healthcare company commits fraud by mislabeling house cleaning services, not covered by Medicare, as a nurse visit in order to receive payment. A pharmacy filling a patient’s prescription with generic drugs and charging for name brand drugs also represents mislabeling.

Medicaid is a health safety net program that was enacted to provide health care coverage to qualifying members of the population with low incomes and has become one of the largest payers for health care in the United States. In 2010, the Medicaid program was responsible for providing health services to over eight million women and covered over forty percent of all births. This gives Medicaid the distinction of being the majority payer for all maternity services in the United States.

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

What are the impacts of these laws and policies on the war against health care fraud?

It troubling to know that unethical behavior is still so rampant in our society today. Managers are supposed to led by example and that is so not the case anymore, everyone just thinks about themselves, how they can achieve more by any means necessary. It was a good judgement call on your part to leave this agency. However, as a citizen and tax payer it was your duty to report what you had seen. Whenever you suspect Medicaid fraud, you can report it by contacting the State Medicaid Agency in your state. You can also call the governor’s office, your senator’s office.