National Health Care Anti-Fraud Case Study

After years of schooling and hundreds of thousands of dollars in debt, doctors aren’t even able to work on their own terms. “Consumers allegedly have a “right” to what health care providers provide, a “right” to say what will be provided, when, and at what price” (Salsman 2012). Consumers shouldn’t have a “right” to what is provided to them or how much it costs. The government controls pricing and controls who can receive care and what kind. It’s not right that those who are actually working in the medical profession that they have lost control of their businesses.

In a survey conducted in 2003, it highlighted that the recurrent problem is the reimbursement rate from Medicaid to the physician (O’Shea, 2007). The Center for Studying Health System Change (HSC) show that 21% of physicians that state they accept Medicaid have reported they will not accept a new Medicaid patient in 2004-2005(O’Shea, 2007). This number would only logically be assumed to have risen in 2013 A survey conducted by the U.S. National Health reported that researchers have found two standout trends among Medicaid beneficiaries: they have more difficulty getting primary care and specialty care and they visit hospital emergency departments more often than those with private insurance (Seaberg, 2012). The lack of primary and specialty care access is mostly contributed to the following barriers; unable to reach the MD by phone, not having a timely appointment with the MD and lastly unable to find a specialty MD that will accept Medicaid. In a recent report released by the Partnership to Fight Chronic Disease, it stated that about 30% of Medicaid patients experience “extreme uncoordinated care”, there is a strong correlation between this situation and higher Medicaid spending and less quality of care given (Bush, 2012). After January 1st 2013, healthcare providers have experienced a 2% reduction in payments for Medicaid beneficiary, this will only create more of a problem for these patients to seek the

Health care fraud and abuse is a significant contributor to high health care spending, resulting in the wasteful spending of health care dollars. The Federal Bureau of Investigation (FBI) and National Health Care Anti-Fraud Association (NHCAA) estimates that 3 to 10 percent of health care dollars are lost to fraud and abuse (Federal Bureau of Investigation, 2010). Fraud is the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the deception could result in some unauthorized benefit to themselves or some other person (Ryan, 2006). Bloomberg reports health care expenditures are rising faster than the rate of inflation and spending in the US has nearly doubled in the last decade and one-half of health care

Critics believe that the present functioning of managed-care is degenerative to health care. Managed-care firms control costs by requiring patients to use a “network” of approved doctors and hospitals, and by reviewing the actions of doctors. Patients have to pay more to visit a doctor who does not participate in the “network.” Managed-care firms second-guess doctors, considering only the costs. Patients are often prevented from visiting specialists to reduce costs. A managed-care company might insist that its doctors prescribe inexpensive generic drugs instead of commercial products. Many patients must, also, receive the insurer’s approval before undergoing treatments or operations. HMOs have been criticized for refusing to pay when a patient goes

Another factor that has contributed to the over-utilization and increased treatment charges is the fact that providers set the prices for services. Patients were free to seek any type of healthcare services that they thought they required for their well-being, while providers set the costs for each service that was billed to indemnity insurance companies (Shi & Singh, 2015). Insurance companies had little control on the types of services that the patient received and prices billed for each service. The fee-for-service model encourages excessive and unwarranted procedures and offers no incentives to utilize economical services

According to the Federal Bureau of Investigation (FBI) “health care fraud costs the country an estimated $80 billion dollars a year” ("Health Care Fraud," n.d., p. 1). Because health care costs continue to rise more rapidly than the rate of inflation the threat of health care fraud continues to rise. The Affordable Health Care Act has put new policies in place to identify and stop health care fraud. The FBI along with other government, insurance, and public agencies have joined together to combat fraud at every level. New rules in identifying, investigating, and prosecuting fraud before payments are made to medical providers could save billions of

The doctor with the highest percent of denials receives a bonus from Humana Health Insurance. Even people who are fully covered by their insurance get denied when they need it the most. In the Sicko documentary by Michael Moore, for example, Tarsha Harris was approved by Blue Cross for her operation but then they discovered that, in the past, she had a yeast infection. Because of the disclosed yeast infection Blue Cross dropped her and told the doctors they were taking back their money. It is upsetting to read about how so many people skip regular checkups because they cannot afford them; then a few years later arrive at the emergency room with an illness that could have been prevented if they had been treated earlier.

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.

Public healthcare applications inclusive of Medicare and Medicaid are particularly conducive to fraudulent activities, as they're frequently run on a price-for-carrier shape.[20] Physicians use several fraudulent techniques to reap this give up. These can consist of “up-coding” or “upgrading,” which involve billing for more high-priced treatments than the ones surely provided; presenting, and in the end billing for, remedies that aren't medically essential; scheduling greater visits for sufferers; referring patients to different physicians when no in addition treatment is really important; "phantom billing," or billing for services now not rendered; and “ganging,” or billing for services to own family members or other people who are accompanying the affected person however who did now not in my view receive any offerings.[20]

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.

Even though Medicaid is a health insurance program for low income individuals, having coverage does not guarantee access to a physician and many of these patients are going without needed care (American College of Physicians, 2015). In the past Medicaid has been known to pay well below what private insurance and Medicare pays for primary care services and is one of the top reasons many providers do not participate in Medicaid (American College of Physicians, 2015). “In 47 other states Medicare pays up to 67% less than Medicare for the same primary care services” (American College of Nurse-Midwives, 2015). A study published in the New England Journal of Medicine states that

One of the greatest changes in healthcare in the past ten years has been the rise of managed care, much to the displeasure of many patients and physicians alike. Managed care arose out of concern about spiraling healthcare costs and was designed to encourage physicians to give patients treatments that were cost-effective out of their own financial interests. "The consumer strategy was directed at imposing some barriers to use by levying various forms of co-insurance. The most common approaches used either deductibles (where the consumer paid the first portion of the bill a technique familiar in other types of insurance) or co-payments (where the consumer paid a portion of the bill and the insurance company the rest) or a combination of both' (Kane et al 1994). Managed care has given health insurance companies an increasingly significant voice in how treatment is administered and allocated. Managed care has proliferated in the past decade despite considerable criticism of the practice of 'nickel and diming' patients as well as the considerable bureaucratic red tape it is has generated. Also, research indicates that healthy, well-insured patients tend to over-consume care without meaningful co-pays but poorer, sicker patients can be deterred even by moderate co-payments and suffer negative health consequences (Kane et al 1994). However, managed care has not gone away and is a reality that all healthcare

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.

These crooks are the possible cause of ruining the reputation of the most trusted and appreciated professionals of our society – physicians. Healthcare fraud can be committed in a variety of ways, but three of the most widely used are described below. The first and most widely known, is billing services that were never endured by using general patient information. When giving personal information out, many hand it over to the front desk assistant at the local doctor. These appear to be people are some of the most known to scam the information and bill patient’s payments that never took place. Keep in mind that when handing over information, the handler is a trusted individual with a good reputation. On the other hand, many are scammed for the opposite; otherwise known as “upcoding,” where patients are billed more expensive services that were actually done. In fact, according to USA.gov a new study showed that 7 percent of identity fraud victims this year reported identity thieves stole their health insurance information, rising up from just 3 percent last year (Federal Bureau Investigation, 2010). This includes the latest scam, called “unbundling,” where scammers con bills and bill each step of a procedure as if it were a separate making the individual pay even more money, leaving devastating effects for the victim. All of which have a common goal of making taxpayers, insurance companies, and

A business can not work out without an account system, which includes internal. Internal controls are used by companies to make sure financial information is accurate and valid. Strong internal controls are signs of a financially healthy company and protect the company’s integrity. Strong internal controls can also increase a company’s profitability. There are several types of internal controls that companies used to protect themselves such as: Segregation of duties, asset purchases, supervisor review, internal audits and adequate documents and records. This paper will discuss several topics from a case study about And the Fraud