Statistics Of Medicaid Fraud That Will Shock You

The Brooklyn District Attorney’s office, DA Ken Thompson, charged Eric Vainer and his mother Polina Wainer who own a Durable Medical Equipment clinic is also the mastermind along with twenty-three other defendants including nine doctors from different medical clinic across the borough of the Bronx, Brooklyn and Queen with $7 million dollars in Medicaid and Medicare Fraud between October 1, 2012, and September 30, 2014. Moreover,

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

Annually, America spends trillions of dollars on health care. To be more specific, roughly ten thousand U.S. dollars is used per person. However, health care fraud costs our nation about sixty-eight billion dollars every year. Being that, thousands of families are exploited and forced to undergo risky medical procedures. In addition, an individual's lawful insurance information and private medical record are used as false claims against them. As a result, it is worrisome seeing a family who could afford the means easily but still embezzles a member ID card that does not belong to them; while single mothers with several children are being rightful and properly paying for Medicaid or other programs while they have a low-income salary.

Once again, another story of billing fraud in a medical practice made news this past week in Becker’s Hospital Review “Medical practice manager sentenced to prison of billing fraud” on April 6, 2017, by Ayla Ellison.

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

Although Congress has used several anti-fraud measures to protect the federal government health care programs, the False Claims Act of 1986 has become the main weapon that government prosecutors use against perpetrators of health care fraud. Designed to prevent fraud and other abuses in federal government programs, the False Claims Act has been the primary statute the government has used in its fight against health care fraud. However, government prosecutors do not rely on one statute in their prosecution of alleged cases of health care fraud. Instead, they rely on a combination of statutes, but the False Claims Act has emerged as the main statutory weapon.

The reality is that healthcare fraud negatively impacts everyone in the nation. "Health care identity theft dominated all other crimes in the sector last year, according to Louis Saccoccio, executive director of the National Health Care Anti-Fraud Association (NHCAA), an advocacy group whose members include insurers, law enforcement and regulatory agencies" (Kavilanz, 2010). Groups of organized criminals are hacking into the digital databases of healthcare organizations so that they can take money from the Medicare system, which means that the government is actually the sole largest victim of health care fraud, according to the FBI (Kavilanz, 2010). The scope and vastness of such crimes truly impact everyone. The money that is stolen not only undermines the integrity of the healthcare system as whole, but is taken away from organizations and individuals who truly need it to help people fight fatal diseases, to help them overcome chronic conditions, to put them back to work and reunite them with their families. Fraudulent activity not only compromises the integrity of the entire healthcare system, but takes numerous victims, impairing the healthcare system from accomplishing the full extent of their goals.

One example of many health insurance fraud cases involves a $115 million whistleblower settlement involving Park Ridge Hospital and Adventist Health System. The lawsuit arose when three longtime employees of Park Ridge hospital had creditable insider knowledge about the hospital paying kickbacks to physicians’ who were intentionally referring their patients to the hospital for illegal monetary incentives. The civil suit also alleged that the health system was overbilling patients for medical services. One example of the overbilling is when Park Ridge Hospital devised a scheme with partnering physicians to perform outpatient procedures inside the hospital for higher reimbursement when in fact the procedure could have be done in an office setting at a lower cost. The act of health care fraud not only financially hurts the victims but it also compromises the quality of the patients care and puts patients’ health at risk. Adventist Health System agreed to settle the lawsuit with the United States government for $115 million dollars which includes the whistleblower’s reward, which will roughly amount to a little over $118 million after legal fees are calculated (Moss,

When an individual or family does not have insurance, and can not or does not pay their medical bills, the cost of that care is "shifted" to patients who do have insurance. For example, a study done by Harvard University found that 50 percent of all bankruptcy filings were partly the result of major medical expenses. The average medical expenses in these bankruptcy filings were $12,000. And someone files bankruptcy every 30 seconds in this country. (National Coalition on Healthcare, 2005, Facts on health care costs). Most of those lost dollars are shifted to consumers in higher premiums and costs.

Insurance fraud has caused the government to tighten its declaration against these unlawful practices. The Health Insurance Portability and Accountability Act of 1996(Braun and Cox, 2005). This Act led to the formation of the Health Care Fraud and Abuse Control Program which is responsible for overseeing, investigating and prosecuting those who commit fraudulent acts related to insurance fraud. This a reasonable risk that clinicians make when misdiagnosing to receive reimbursement or for purposes for treatment to be paid for by the third party

According to the legal dictionary, "health care fraud is a type of fraud that involves the use of our health care systems by an individual, medical provider, insurance company in a dishonest manner to profit from it" (Health Fraud). Fraud includes single groups of people, employers and government supplying false information, claim services or documentation that was never provided, changing patient or doctors signatures or changing medical records to establish misrepresented services, and even submitting a request twice. While health care fraud may not be a label as everyday crime people and business touches, hurt and even destroyed by this act. This crime has caused an insurance premium to skyrocket for individuals, small companies, and corporations

This type of fraud is not limited to Medicare. The term "healthcare fraud" encompasses various types of fraud. These are cases where individuals submit false claims to the government for payment. The fraudulent claims may involve any government healthcare program. Healthcare fraud may involve violations of many laws including the false Claims Act and the Social Security Act.

In 2004, it was reported that healthcare had one hundred fifty billion dollars in losses due to health insurance fraud and abuse. Health insurance fraud and abuse can waste up to one-tenth of healthcare resources. Fraud and abuse also affects the consumer as it causes for the rise in premiums, less benefits, increase taxes and higher copayments. The occurring fraud and abuse also puts patients through unnecessary test and procedures for health insurance claims. Having an aggressive stance on preventing fraud by having a outsourced program established can help prevention in loss and harm to patients. Educating the organization on how much fraud can cost, and that patients are putting trust into the care they receive, expecting to not be deceived.

According to Centers for Medicaid and Medicare Services, Medicaid fraud is said to be “knowingly or willingly misrepresenting the truth to defraud and obtain money or property of healthcare benefit program” while abuse happens “when doctors or health care providers perform activities that directly or indirectly result in unnecessary healthcare costs in healthcare program”. Many state that if regulation is made on unnecessary services, then there will be reduction in the cost of spending on the Medicaid. The most common types of fraud and abuse that occur in Medicaid are billing for services not performed, double billing, substitution of generic drugs, unnecessary services, up coding, kickbacks, unbundling, cost reports and identity theft or use of provider numbers. All these frauds and abuses increases strain on Medicaid Trust Fund. According to Medicare Fraud Control Units (MFCU) for the fiscal year 2013, annual reports on number of cases registered for fraud and abuse are shown in the below figure.

One of these requirements includes compliance with billing and collection practices including anti-fraud activity. CMS and OIG directly enforces Stark, AKS and False Claims act resulting in penalties being assessed through the Federal Sentencing guidelines, Section 8 and violators being placed on the OIG exclusion lists. Physician Self-Referral Law (Stark Law) prohibits a physician from making a referral for certain designated health services to an entity in which the physician (or member of his or her immediate family) has an ownership/investment interest or with which he or she has a compensation arrangement, unless an exception applies. Anti-Kickback Statute (AKS) makes it a criminal offense to 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. False Claims Act (FCA) protects the government from being overcharged or sold substandard goods or services. The FCA imposes civil liability on any person who knowingly submits, or causes the submission of, a false or fraudulent claim to the Federal government. The “knowing” standard includes acting in deliberate ignorance or reckless disregard of the truth related to the