Medicare Fraud Research Paper

fraud risk exclusion from participation in Federal health care programs and the loss of their

WEEP is both unique and promising because the program focuses on education of the elder and their caregiver simultaneously. This combined learning experience will strengthen the elder-caregiver relationship, increase financial knowledge, while improving awareness of fraud and exploitation, thus leading to increased reporting and more prudent behavior. The U.S. Department of Justice and the Department of Health and Human Services outlined in the Elder Justice Roadmap (PBS, 2014) ways in which elder exploitation can be combated through awareness, education efforts to support caregiver(s), and supportive education resources in the community. The Roadmap suggests that there should be better support for the tens of millions of paid and unpaid

Medicare fraud occurs when individuals or companies attempt to collect Medicare payments under illegal and false payments. There are many schemes, but they all have the same goal in mind. That goal is to make money by defrauding people.

Medicare covers over 47 million Medicare Beneficiaries. This includes 39 million seniors and 8 million people under 65 receiving social services disability insurance (SSDI) payments due to permanent disabilities (Kaiser Family Foundation 2010). Medicare accounts for 12% of federal spending, 23% of national health spending, and is critical part of policy discussions related to the federal budget and the 2010 Health Reform Law (Kaiser Family Foundation 2010). Medicare’s financial problems affect the entire budget, and are largely responsible for projected increases in federal deficits (Peter G. Peterson Foundation 2010).

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,

The historical background of Medicare is explained by answering many different questions. One of the historical problems which led the creation of Medicare was that the health costs for the elderly increased dramatically, while a person’s income is also declining. Many of the elderly were unable to afford health insurance, which led to a large amount of people not being covered by any health insurance. There were also certain companies that decided to terminate health policies for those who were considered to be high risk. The problems historically were very important in the fact that insurance companies were charging the elderly too much, and it didn’t just affect those who were already financially unstable. This problem was handled previously by different Federal-State programs that were set in place for medical assistance, but they were not meeting the needs of the people. Often, people were turned away and many were not eligible for the programs.

Medicare fraud investigations, if wrongdoing is found, may result in a civil lawsuit or a criminal case. Anyone who receives a letter or a visit announcing that they are under investigation should consult an attorney specializing Medicaid fraud

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

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.

Medicare is administrated by the Centers for Medicare and Medicaid Services (CMS). It is divided by subdivisions which is the Center for Medicare Management who overseas development of payment policy and management of fee-for-service contractors. The Center for Beneficiary provides beneficences with information on Medicare programs, and research grievance and appeal functions. The Center for Medicaid and State Operations focuses on federal and state programs like Children’s Health Insurance Program and the Clinical Laboratory Improvement and CMS who enforces insurance portability and transaction and code set requirements of HIPAA.

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 billing for services not rendered for are often done as a way of billing Medicare for things or services, that basically never occurred. This can involve forging the signature of those enrolled in Medicare or Medicaid, and the use of bribes or as Healthcare calls it, kickbacks to corrupt healthcare professionals. Upcoding of services is the act of billing Medicare programs for services that are more costly than the actual procedure that was done. Upcoding of items is also very similar to upcoding of services, but it involves the use of medical equipment. For example, billing Medicare for a highly sophisticated and expensive wheelchair, while only giving the patient a manual wheelchair is upcoding of items. Duplicating claims occur when a provider does not submit exactly the same bill, but alters small things such as the date in order to charge Medicare twice for the same service rendered. Therefore rather than a single claim being filed twice, the same service is billed two times in an attempt to receive payments from the government twice. Unbundling involves bills for particular services are submitted as fragmentary, which appear to be staggered out over time. Although, these services would normally cost less when bundled together, but by manipulating the claim, a higher charge is billed to Medicare resulting in a higher pay out to the party committing the healthcare fraud. Excessive services occur when Medicare is billed for something greater than what the level of

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.

The Federal Bureau of Investigation is spending large amounts of its budget to crack down on health care fraud. Special units have been formed to help the FBI Crimes Section find these

Medicaid or ACA fraud can be conducted in a manner of ways, the most common seen are; Medicaid billed for services never done and equipment that was never used or was returned, d documents that were altered to receive higher payments, misrepresentation of dates, descriptions of furnished services, or the identity of the beneficiary, use of a person’s Medicaid card and ACA without the persons permission, and a company that uses false information to mislead someone into joining a Medicare plan (Collica-Cox, 2015).