Medicare Fraud Case Study

We have recently learned the Department of Health and Human Services is investigating Houston Methodist for Medicare fraud. We will cooperate with and respect the officials conducting the investigation and are confident we will be exonerated of all allegations. We believe that we will be found innocent once the investigation is complete.

As a whole, the authors of the articles shed light to the inequality of medical care among Medicare recipients depending on the region. Not only inequality, but even with those individuals that received large care, there was no notable difference of their overall health with those that spent least. In other words, the amount spent on Medicare patients has no correlation with better health or higher quality of life. On the contrary, Medicare patients that received the most benefits were deemed to have life-threatening conditions. Although the uncovered such information, they suggested new approaches to improve the Medicare program, focusing on a population-based approach and accountability for all hospitals and

Attempts to stop fraud were enhanced under Public Law 104-191, the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The purpose was to improve the Medicare program under title XVIII of the Social Security Act, the Medicaid program under title XIX of such Act, and the efficiency and effectiveness of the health care system. This public law encouraged the development of a health information system through standards and requirements for the electronic transmission of certain health information (aspe.hhs.go). The Act established a program to take action against fraud committed against public and private health plans. The legislation required the establishment of a national Health Care Fraud and Abuse Control Program (HCFAC), under the joint direction of the Attorney General and the Secretary of the Department of Health and Human Services (HHS) acting through the Department 's Inspector General (HHS.gov). The HCFAC program is designed to coordinate Federal, State and local law enforcement activities with respect to health care fraud and abuse. The Act requires HHS and Department of Justice (DOJ) detail in an Annual Report the amounts deposited and appropriated to the Medicare Trust Fund, and the source of such deposits. (HHS.gov) I will summarize the impact of these laws as it pertains to how they are impacting the healthcare delivery system. (HHS.gov)

Are you aware of the various policies that are being enacted from each state to state regarding the qualification of Medicare? Medicare is funded by the federal government and each state is responsible for operating the

Another reason why policy maker are concern is due to sharp practices by provider, they shift costs from one program to the other, exploring the loopholes in the payment structure which can lead to greater fragmentation in care and risk of patient. An instance is when patients shifted from a nursing home, where Medicaid is paying the benefits, to a hospital, where Medicare pays, mainly to maximize provider reimbursement.

You’re sitting at home one afternoon, three weeks prior to the start of Open Enrollment, when you get a call from a friendly Center for Medicare Services (CMS) employee. The caller tells you that Medicare is issuing “new cards,” and that you need to provide your Medicare number, birth date and social security number in order to get yours. The catch? The caller doesn’t work for CMS, and he’s actually trying to steal your identity. Elder abuse is one of the most common crimes of the 21st century. In fact, studies have shown that 2 in 10 older adults have been financially exploited. Read on for 5 tips on avoiding common types of Medicare scams.

Author Donald A Barr defines the Medicare program. “The federal Medicare program is our system of universal health insurance for everyone sixty-five years old or older paid through a general withholding tax” (Barr 131). Unfortunately, the United States Medicare system is financially unstable. “Medicare is spending more money than they are bringing in…Policymakers are looking at several different options that will alter the Medicare program significantly” (WPC 2). In turn, a high number of companies and organizations are investing their time and revenue into lobbying to make healthcare changes. Joe Eaton from the Center for Public Integrity shares “More than 1,750 corporations and organizations hired about 4,525 lobbyists — eight for each member of Congress — to influence health reform bills in 2009” (Eaton). The objective for special interest groups is to pull financial resources together to be a force of influence. Granted there is strength in numbers, for example, the American Association of Retired Persons (AARP) “deployed fifty-six in-house lobbyists and two from outside firms to work the issue on behalf of its members. Also, American Medical Association (AMA), “spent $20 million overall in 2009 lobbying Congress on behalf of doctors” (Eaton). The AMA was successful in removing a $300 fee for physicians that participate in Medicare and Medicaid. Furthermore, the AMA advocated for budget cuts for higher income Medicare subscribers and payment cuts for Medicare biller’s

The newspapers are flooded daily with articles about medicare frauds and abuse, consisting of corrupt physicians, pharmacists,executives and at times even the whole institution maybe involved in frauds worth millions of dollars . It is very essential to figure out the structural and functional loopholes which the allows such large amounts of frauds (Rivlin,

Medicare is national government run program that was developed in 1965. Medicare provides health insurance to Americans aged 65 and older who have worked and contributed to the program throughout their whole life by utilizing around 30 private insurance companies. The program also assists in providing benefits for younger people with disabilities. As well as offering Medicare in the United States a program called Medicaid is also available. Which is also a government run program, Medicaid is a state run program that provides hospital and medical coverage for people with low income (Medicare, 2015). With Medicaid being a state run program that allows each state to have different rules and regulations for who is and isn’t eligible as well as if they move across state lines. The programs listed above have helped many Americans over 65 and have a low income to be able to afford healthcare and receive the proper services for their healthcare concerns and issues. With any program and especially a government program there are going to be people who use and abuse the process which leads to Medicare and Medicaid fraud. There are many forms of fraud in Medicare and Medicaid such as billing for equipment or services that weren’t needed, falsifying health issues, dispensing generic prescriptions but billing for name brand. With there being so many types of fraud and investigations happening more and more due to the fraud that is occurring, people are finding more and more ways to

To compensate for such fraud, states must either raise taxes or decrease services in other areas. Those who most need Medicaid services may not be able to obtain benefits because resources are not available. For patients, Medicaid fraud could mean tampering with their medical records, which could put their health at risk. People can get hurt when doctors or other providers give less or more care than needed just to make more money. Also the public is more skeptical about social service programs as more incidents of Medicaid fraud occur every day. Providers and facilities who commit Medicaid fraud can face penalties from state and federal governments.

Medicare and Medicaid have cause a great deal of damage to the American society. "Years of scandal have shown the waste, fraud and abuse that is rampant in Medicare and Medicaid." (Fallen Guardians of Justice: How the Supreme Court is

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.

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

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.

Health care has become a target for unscrupulous individuals. Both private industry and government are employing a variety of tools to combat fraud and abuse. Since 1992, we have made tremendous progress in protecting the fiscal integrity of the Medicare program. An example is the HCFA initiated partnership with the enforcement agencies targeting fraud and abuse in those five states that account for nearly 40 percent of all Medicare and Medicaid beneficiaries. This two-year project, Operation Restore Trust, encompassed a wide range of projects aimed at eliminating fraud schemes and identifying vulnerabilities in the Medicare programs. The reforms enacted in the Balanced Budget Act of 1997 and the Health Insurance Portability and Accountability Act of 1996 provide significant new tools to further assist us. But I think we all know that equally tremendous challenges he ahead. Our goal is to ensure that the Medicare and Medicaid programs have the necessary arsenal to combat fraud and