Research Paper On Medicaid Fraud

In present times, people with high incomes that’s above the 100 percent poverty level is eligible for premium subsidies to purchase private plans in the health care market. Individuals that are below the 100 percent of poverty in states that don’t wish to expand Medicaid; do not have access either to subsidized private coverage or Medicaid (Garber & Collins, 2014). Originally, the law require that all states expand Medicaid eligibility, to enable those people living with income that is increasing to 138 percent of the poverty level. These factors are equivalent to $15,856 for each individual and $32,499 for a family living in a single dwelling (Garber & Collins, 2014). In 2012, the Supreme Court made these regulations optional for ruling.

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 are programs that have been developed to assist Americans in attainment of quality health care. Both programs were established in 1965 and are federally supported to provide health care coverage to vulnerable populations such as the elderly, the disabled, and people with low incomes. Both Medicare and Medicaid are federally mandated and determine coverage under each program; both are run by the Centers for Medicare & Medicaid Services, a federal agency ("What is Medicare? What is Medicaid?” 2008).

On November 21, 2013, Theanna Khou pleaded guilty to dispensing and selling OxyContin from his Huntington Pharmacy without medical necessity from fraudulent prescriptions issued by a clinic (" Health care fraud investigations," 2014). Khou billed Medicare for filling prescriptions that patients never received. This story is becoming a norm for the health care industry, because the growing financial prosperity of the health industry. Corruption and crime is changing, turning from drug dealing to a safer haven that has less legal management, organization, and more wherewithal the business of health care fraud.

Each state has their own policies for Medicaid eligibility, services and payments. Medicaid plans have three eligibility groups such as categorically needy, medically needy and special groups. Children's Health Insurance Program (CHIP) is a program that offers health insurance coverage for uninsured children under Medicaid. If Medicaid does not cover a service, the patient may be billed if the following conditions have been met such as the physician informed the patient before the service was performed that the procedure was not covered by Medicaid and if the patient has signed an Advance beneficiary Notice form. However, there are also conditions where the patient cannot be billed if necessary preauthorization was not obtained or service

In 2009 there were 50.7 million people, 16.7% of the population, without health insurance. Americans all over the country are working and yet they still can’t afford to pay the high cost of health insurance for themselves and their families. Under the Affordable Care Act of 2010, which was signed by Obama on March 23, 2010, thirty two million Americans who were previously not eligible for Medicaid may now have the opportunity to be covered. If this act is passed in North Carolina then it will be expanded to cover nearly all of the 1.5 million North Carolinians who are without health insurance. If more Americans are covered under the Medicaid that they need then

Texas has the largest uninsured population with an estimated 6.2 million uninsured citizens within its stateliness, approximately a quarter of the statewide population (Rapoport, 2012). In 2012, then governor, Rick Perry decided that Texas would not expand Medicaid under the Affordable Care Act (ACA). This decision led to much debate over whether or not Perry made the right decision to leave upwards of a million Texans, who did not receive insurance subsidies and did not qualify for Medicaid, uninsured. These Texans fell under what many politicians refer to as the “coverage gap.” Texas decided not to expand Medicaid under the Affordable Care Act because of the effects it would have on hospitals, financial reasons, and increased number of

The U.S. health care system is a scrutinized issue that affects everyone: young, old, rich, and poor. The health care system is comprised of three major components. Since 1973, most Americans have turned to managed-care programs, known as HMOs. The second type of health care offered to Americans is Medicare, health care for the elderly. The third type of health care is Medicaid, a health care program for the poor.

On March 23, 2010, President Obama signed the Affordable Care Act (ACA) into law, allowing all Americans access to affordable health care. Despite the urgent need to provide health care to all Americans some Governors and elected Congressmen continue to debate over the necessity to expand Medicaid and the ACA. The Supreme Court on June 28, 2012 ruled in support of the ACA by upholding the individual mandate which require Americans to have health care insurance. Americans without health care insurance, because of this new health care policy will be able to either purchase insurance through the exchange market or through the expansion of Medicaid. Some states are against the expansion of

Collectively, the Department of Health and Human Services and the Department of Justice work to reduce healthcare fraud and investigate dishonest providers and suppliers. The Health Care Fraud Prevention and Enforcement Action Team recouped almost 3 billion in fraud, this year alone. Also, aggressive strategies exist to eliminate Medicare prescription fraud. Patients abusing or selling painkillers received by visiting several doctors and obtaining multiple prescriptions costs Medicare millions annually. Fraud affects everyone, preventing it requires government officials and citizens diligently working together.

Medicare and Medicaid are two of the United States largest broken systems, which must sustain themselves in order to provide care to their beneficiaries. Both Medicare and Medicaid are funding by a joint effort between the federal government and the local state government. If and when these governments choose to cut funding or reduce spending, Medicare and Medicaid take the biggest hit. Most people see these two benefits as one in the same, two benefits the government takes out of their pay check to help fund health care. While the government does deduct a sum from paychecks everywhere, Medicare and Medicaid are very two very different programs.

According to the website Medicaid.gov, the Affordable Care Act would increase the number of people that are covered by Medicaid, and would lower health care costs, and would Guarantee more choice of health in insurance. This is a great idea, but their downfalls in the program like the increase, tax of people, and when “U.S. health care spending, which reached nearly $8,000 per person annually in 2009, has outpaced GDP growth for the past several decades and far exceeds spending in any other country.” (Squires, 2012) also, there are steps that the people who truly need the help must go through to get these programs especially those you fell in coverage gap like “2.6 million people in 18 states are in the "coverage gap." More than

Medicaid and Medicare are two different government programs. Both programs were created in 1965 to help older and low-income families be able to buy their own private health insurance. These programs were part of President Lyndon Johnson’s “Great Society” plan, a commitment to helping meet the needs of individual health care. They are social insurance programs, which allow the financial load of patient’s illnesses to be shared by other healthy, sick, wealthy, and lower income individuals and families.

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

This study sought to answer three research questions. Although the questions have been presented in previous chapters, they are worth presenting again.