Medicare Fraud Research Paper

Federal or state authorities may investigate allegations of fraud depending on where the fraud was reported, the laws broken, and the amount of money involved. The strictness of penalties levied by state governments varies from state to state. Federal laws such as The False Claims Act, Anti-Kickback Statute, and Social Security Act are laws that address fraud and abuse. Title XI of the Social Security Act contains Medicaid program-related anti-fraud provisions, which impose civil penalties, criminal penalties, and exclusions from federal health care programs on persons who engage in certain types of misconduct (Staman, 2010). Under federal regulations, providers convicted of fraud are excluded for a minimum of five years from receiving funds from any federally

After establishing Medicare and Medicaid in 1965, Congress saw the need to protect the programs from fraudulent activities and practices of unscrupulous providers. The laws on health care fraud were enacted at different time during the history of the health care programs. However, the overall congressional intent has been the same, and the objective is to strengthen existing laws to protect the federal government health care programs from fraudulent activities.

 Receiving workers' compensation benefits that are not entitled to the claimant;  Making false or misleading statements with the purpose of securing goods or services under the Workers' Compensation Act;

The pharmacist submitted claims for reimbursement on brand name medications rather than on the less expensive generic drugs that were actually dispensed. This is a result of health care fraud on Medicare part D, which is in violation of the False Claims Acts (FCA) and anti-kickback statues. "The FCA protects the government from being overcharged or sold substandard goods or services" (CMS, 2015). The federal Anti-Kickback Statue is designed to protect patients and federal health care programs from fraud and abuse. It states "that anyone knowingly and willfully offer, pay, solicit, or receive any remuneration directly or indirectly to induce or reward referrals of items or services reimbursable by a Federal health care program" (CMS, 2015)."The

Medicare fraud is illegal and remedies are sought at both a civil and criminal level. If a provider, practice, or institution is found guilty of Medicare fraud, the consequences may include a loss of license, monetary penalties, and the inability to participate in Federal healthcare programs. The Office of Inspector General (OIG), which is a part of the U.S. Department of Health & Human Services, has the ability to exclude individuals who participate in Medicare fraud. The guilty party will be listed on a searchable database on the OIG website. The list is officially referred to as the List of

The penalty will come in the form of being disallowed Medicaid benefits for a set period of time. This time period will be determined by the value of the assets that were "improperly allocated" in the eyes of the many bureaucratic regulations of this joint federal-state program.

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

This paper deals with the legislative, regulatory components of Medicare Readmission Reduction Program along with recommendation to reduce their readmission rates for a health care facility like Valley hospital in Spokane which has been penalized a higher percentage of 2% as compared to other hospitals in the state of Washington under the third round of penalties.

The Stark Law 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).”

The DOJ and HHS created the Stop Medicare Fraud website, which provides information about how to recognize and protect against Medicare and Medicaid misrepresentation and how to report it. In conclusion, the government has moved away from the inefficient and costly fee-for-service payment type and moved toward the value-based reimbursements for health services to help increase patient care and quality outcomes. I believe the FCA and AKS regulatory laws are able of guarding against overutilization, raised costs, and poor quality of care and I look forward to this being debated in the

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)

Enforcing this act in the healthcare facility is necessary for healthcare administrators to be aware of facilities that receive patients, provide care, and cease unnecessary transfers to avoid the lack there of. “This means if a patient arrives at a hospital that accepts Medicare, the hospital isn’t allowed to refuse patient care, and this protection also requires healthcare providers to assess and stabilize all patients regardless of financial status”, (American Health Lawyers Association.

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

They are the False Claims Act (FCA), the Anti-Kickback Statute (AKS), the Physician Self-Referral Law (Start law), the Exclusion Authorities, and the Civil Monetary Penalties Law (CMPL). The FCA protects the Government from being overcharged by health care providers filing false claims. Under this law, specific intention to defraud is not required. The AKS prohibits the knowing and willful payment of remuneration to induce or reward patient referrals or the generation of business involving any item or service payable by the Federal health care programs (U.S. Department of Health & Human Services). The Physician Self-Referral Law, also known as the Start law, prohibits health care providers from referring patients to entities with which the provider or a family member has financial interest. The Exclusion Statute bans certain entities or individuals from participating in federal health care programs. If an individual or organization is excluded by the Office of Inspector General (OIG) Federal health care programs will not pay for services or items provided. The Civil Monetary Penalties Law allows for civil money penalties to be placed against an entity that knowingly submits fraudulent claims, violates Medicare agreements, making false statements on applications for participation in Federal health care programs, and violates the AKS, among other

What is Medicare and Medicaid? Medicare is the federal health insurance program for people who are 65 years or older. Medicare can also be used by Younger people who have disabilities. Medicaid is a jointly funded health insurance program for low-income and needy people. 64 million people are covered by Medicaid.