The Medicare Bill

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

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.

Medicaid and Medicare was created and called the Social Security Act of 1965 to provide coverage for medical treatment for qualified individuals and their families. Medicaid is a program that is jointly funded and managed by the federal and state governments that reimburse hospital and physician for providing care to qualified patients who cannot afford medical expense. To qualify for Medicaid he or she must be a United States or resident citizen which, includes low income adults and their children, people with certain disabilities and senior citizens. “Medicaid and Medicare is overlooked by the Center for Medicare and Medicaid,

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

What is Medicare? President Lyndon Johnson signed Medicare into law on July 30, 1965. When Medicare first began, it had two parts, Part A and Part B. Medicare Part A provides hospitalization coverage to all citizens age 65 and older. It helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities. It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits. Most people do not have to pay a premium for this service because they or their spouse has already paid for coverage through payroll taxes. Most beneficiaries over age 65 don’t pay a monthly premium for Medicare Part A coverage if they or their spouse paid Medicare taxes for at least 10 years while working (Mack, 2016). Most Medicare beneficiaries do not have to pay Medicare premiums on Part A because of their employment Medicare tax history (Mack,

When health care providers file a medical claim on behalf of the Medicare patient, it is being filed with the Federal Government, which certifies that the provider earned the payment requested and that the provider also complied with billing requirements. Improper claims are categorized as erroneous and fraudulent claims. Erroneous claims can be classified as applications for reimbursements where innocent and common coding and billing errors have been made. Id. Whereas, fraudulent claims are classified as applications for reimbursements with reckless and international conduct to collect payments for services not provided. Id.

1960- President Lyndon Johnson cryptograms Medicare into law providing complete health coverage for individuals age 65 and over. By the end of the 1960, 69% of clinicians are

In 2010, through President Barrack Obama’s advocacy, the United States enacted the Patient Protection and Affordable Care Act (“PPACA”) in an effort to ensure that all Americans have access to health coverage. As part of the PPACA Congress directed the Secretary of the U.S. Department of Health and Human Services (“HHS”) to develop and implement a Medicare Self –Referral Disclosure Protocol. The SRDP is intended to foster the resolution of potential or actual violations of Stark. This Section will give an in depth look at disclosures prior to SRDP, its enactment and the important developments in its brief existence.

Having been instituted on July of 1965 by President Lyndon, Johnson, for 50 years now, Medicare has served as a means of of health insurance for individuals 65 and above. This program has served as a means of getting healthcare to the elderly despite their financial situation. Going back as far as 1912, America had long been aspiring to establish a health insurance policy for Americans, but alas, none of these projects ever got real momentum. That was until 1945 when Harry Truman was elected into office. Truman believed health care for every American was an urgent matter so he requested that congress create a National Health Insurance Policy, which would help every American pay for meticulous things such as routine doctor visits, dental care, and other necessities. Despite his dedication, Truman’s plan deteriorated and nothing was accomplished. Finally, in 1965, Lyndon B. Johnson signed for legislation to establish what we all know today as Medicare.Since then, the program has experienced countless changes coming to cover far more Americans. At the time, it only consisted of Part A and B, but over the years, but has come to include C and D as well. Despite having been created in order to help a wider population, the program has been proven to have aspects of it that ultimately harm consumers.

Fraud and abuse per our textbook can occur by unbundling and billing for a battery of services such as the laboratory tests separately as this was the issue referenced in the District Court Order of Ohio Hospital Association, et. al. v. Shalala. It was identified in number two of the footnotes that “Reimbursement was actually provided by a ‘fiscal intermediary,’ which contracts with the government to make determinations regarding coverage and payment (Ohio Hospital Association, et. al. v. Shalala, 1997).” This fiscal intermediary’s accountability in the case would bring about a discussion regarding if this was an innocent mistake, negligent conduct, or

Medicare is a federal health insurance program. This program pays for a variety of health care expenses for people who are 65 and older, adults with approved medical conditions such as Lou Gehrig’s disease, qualifying permanent disabilities may be eligible. It is financed by payroll taxes, premiums paid by voluntarily beneficiaries, income taxes paid on Social Security benefits and interest earned on the trust fund investments.

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

Medicaid fraud is illegal, but it is still big business. According to the Office Of Management and Budget, Medicare made nearly $47.8 billion improper payments in 2010. This is nearly 10 percent of the $528 billion spent on Medicare. The United States cannot afford to keep dealing with this type of fraud.

In 1965, President Lyndon Johnson created Medicare under Title XVIII of the Social Security Act in order to provide health insurance to people aged 65 and older, without regard to income or medical history. It also includes people under 65 with permanent disabilities, end-stage renal disease (permanent kidney failure) and amyotrophic lateral sclerosis (Lou Gehrig’s disease). Roughly half of all seniors lacked medical insurance prior to 1965. As of 2015, Medicare provides health insurance to 55 million

Fraud and waste of resources allocated for Medicare pose major risks to the program. Medicare is very vulnerable to a number of frauds majorly due to the fact that the program is hardly audited. Medicare scams occur in various ways that include phantom billing where healthcare providers demand money from Medicare for services not offered. The other form of fraud happens in the shape of patient billing where the patients collude with scammers to claim for kickbacks for false medical treatments. The last type of fraud is the upcoding scheme and unbundling, where bills are inflated by claiming that a patient needs more valuable services or procedures than the existing. The government has been sensitizing the general public on the need to avoid such frauds by not disclosing their Medicare card details to