Medical Office Fraud Cases

Physician and pain clinic owner Paramjit Singh Ajrawat, of Potomac, Maryland has been ordered to

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

We are presented with a proposal made by a cardiologist wishing to invest collaboratively with the hospital in establishing an outside heart scanning center. Physician investment in a health care business, to which the physician will then refer, creates a situation ripe for potential conflict of interests. While physician investors may honestly believe the services provided in their facilities are of greater value and higher quality than competing institutions, the utilization of services in which they have a financial interest may well be influenced by the profit motive. Therefore this proposal creates a perfect target for regulatory bodies looking to find physician financial conflict of interest violations.

This booklet is designed to serve as a guidance to concepts of fraud and abuse laws which affect the coding, claims management, charge master and bill reconciliation. It is important to understand the laws as a variety of health care providers’ payment and arrangement activities are prone to fraud which eventually result in criminal penalties and unethical behaviors in health services. To evade associated liabilities, employees should understand the fraud and abuse laws and compliance policies.

The date of service should never be change. In order for the insurance to pay (if they accept to do it), billing should re-submit the claim with the information about that office visit. Medicare usually has a retroactive effective date for Part B premiums, which can be deducted from the lump sum of the SSDI. In some cases, then there may be Medicaid eligibility for a period of time and again, any services obtained during that time could be paid by Medicaid. If Nancy takes a chance and change the date and this action is made, it can lead to an investigation under Medicare Fraud. Medicare claims must be filed no later than 12 months after the date when the services were provided. If a claim isn't filed within this time limit, Medicare can't

I currently work in a nursing and Rehab Facility for Elderly People. Whether it is short term or long term I see a lot of patients file daily. I oversee all their chart filing of insurance claims, SSI, Verification Forms, ID Cards, and Any medical codes that need to match the patients Files. Reading through National Health Care Anti-Fraud Association. (2016) I was shocked to see the amount of fraud that has occurred between 2000 and 2014. When you are going to see your doctor for a physical and you get a physical Exam and this occurs, " medical identity theft victim may unexpectedly fail a physical exam for employment because a disease or condition for which he's never been diagnosed or received treatment has been unknowingly documented in his health record." That is appalling, this patient just now had his job jeopardized,

As we head into the next four years under the Obama administration, many Americans are hearing more and more about healthcare reform and what needs to be done to fix the ailing healthcare system. Part of the dramatic increase in healthcare costs is due to Medicare fraud abuse. Healthcare fraud is defined as making false statements or representations of material facts in order to obtain benefits or payment. Healthcare abuse is defined as practices involving the overuse or misuse of services, either accidentally or intentionally, for various reasons that results in overpayment. These acts may be committed by an individual person or an entity. Fraud and abuse exposes a person, provider, or entity to criminal and

There are federal health care statutes that federalize fraud violations. A false claim violation includes knowingly making a false statement or representation of material fact or billing for services knowing that the individual that provided the service was not a physician and may warrant charges as a felony or misdemeanor (Furrow, et al., 2015). The Federal Criminal False Claims Act criminalizes knowingly making a false claim to the United States Furrow, et al., 2015). Criminal sanctions can also include aiding and abetting, conspiracy, and/or mail and wire fraud (Liebert-Hall, 2017). Criminal sanctions require proof beyond a reasonable doubt and proof of intent to defraud (Liebert-Hall, 2017). These laws are in place to promote positive and honest billing practices in health care.

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

Anyone in the medical field may seem trustworthy because most of the time they are. Unfortunately, there are those individuals who seek financial gain and are no longer trustworthy. There is no exact amount of how much fraud has been committed within the health care system, because it usually is never detected. Like in the case of Dr. Guerrero who committed a healthcare fraud scheme against his patients, employees of the health care system, and health care insurances. According to Vivek Pande and Will Maas, Dr. Guerrero was able to commit fraud against clients and the health care system and insurance providers; it is an ingenious crime, because the public considers them intelligent and high achieving individuals. (Pande & Maas, 2013) Overall, health care providers have a choice

In FY 2014, the Department of Justice (DOJ) opened 924 new criminal health care fraud

As we all know medical fraud and insurance fraud is both a crime, however that does not stop individuals from committing it. Back in 2015 the FBI arrested 46 doctors and nurses across the country. Which was also the largest Medicare fraud bust ever. The individuals billed Medicare for $712 million worth of patient care that was never given. Most of the doctors was ordering durable medical equipment and sending them across the country to patients that did not request nor need them. Since 2007 The DOJ’S Medicare Fraud Strike Force team has gotten over 2,300 people who committed fraud for more than $7 billion dollars. Thanks to the Affordable Care Act there donation has happen catch more individuals .

Timely Home Health Services is under investigation for Medicare Fraud in the amount of over $13.4 million dollars. There are 4 defendants in this case; Okoroji, Ewah, Nwanguma, and Ogwuegbu. The allegations, that have been brought forth, are that between the years of 2007 and 2015, services for home health care were ordered with falsified documents. Once they sent the record to the provider, who ordered home health under the assumption the documents were correct, Timely sent in the claims for home health care for the patient. All 4 are indicted for conspiracy to commit healthcare fraud. Other counts are that Okoroji and Ewah are indicted on 5 counts, Ogwuegbu 4 counts, and Nwanguma 3 counts of healthcare fraud. The case was brought by

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.

Fraud in health care is a major issue, even with all these laws and rules on how on to comply. Here are some of my example on overt, covert, and occult fraud inside the health care system.