The United States : A Multibillion Dollar Industry

Medicare and Medicaid have cause a great deal of damage to the American society. "Years of scandal have shown the waste, fraud and abuse that is rampant in Medicare and Medicaid." (Fallen Guardians of Justice: How the Supreme Court is

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

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

Some estimate that the federal government loses 30 percent of every dollar it spends on medical claims, due to medical billing mistakes and fraud. With so many loopholes and regulations surrounding Medicare, it is impossible for one person to know every nuance. However, constant diligence and ethical practices are a cornerstone of catching and preventing medical billing mistakes.

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

It is easy to see how fraudulent medical billing is having a major impact on the Unites States and the citizens of this country who rely on it on a daily basis. We often hear through the various new sources in this country, on the internet or out of the mouths of politicians and experts in the healthcare field about the failing healthcare system in this country. We often hear many different opinions on what needs to be done to fix our healthcare problem within this country and fix what looks to be a very broken system at this point. No matter what the solution to our poor healthcare system is one thing that is very clear is that healthcare fraud and abuse is playing a major role in the depletion of money in this country and the rise in healthcare costs for the citizens of this country.

This exercise point out some very important factors with regard to health care cost.  nursing homes and other health care delivery systems are faced with significant shortfalls in reimbursement for various reasons.  Medicare reimbursement often does not cover the full extent of treatment of individuals.  McPike (2008) notes that, “The insurance and hospital industries released a study today showing that underpayment by Medicare and Medicaid costs consumers and employers $88 billion more a year for health care as providers attempt to make up the difference.” Today with continue cutbacks in medicare reimbursement this number is significantly higher.  In an attempt to reclaim these losses, both self pay and privately insured patients are charge

Starting in 2014, ObamaCare promised to let citizens keep their doctors and insurance plans. Yet, many Americans soon needed to change plans because all of a sudden their insurance was not “government approved” (Garth Kant). Pulling out a client 's doctor from underneath their feet, should be unconstitutional. Now many Americans are forced to look for a doctor that is “approved” and fits their personal and physical needs. Meanwhile transferring personal medical information can not only be difficult, but are open to the chance of loosing forms and transferring information to the wrong person. Americans who are looking for new insurance companies also have a very high risk of identity theft. Garth Kant, an author from WND’s website, states that:

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)

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]

Health insurance fraud is what drives up health insurance premium costs, wastes taxpayer’s money, but can also endanger beneficiaries or leave them uninsurable. In 2015, Medicare Strike Force reported over $700 million in false billing by doctors, nurses, other licenses medical professionals, laboratories, and individuals (FBI.gov). This is a staggering figure that is only getting worse. In this fictitious federal case I will be describing the criminal offender, the crime that was committed, the charge handed down by law enforcement, and the judicial process from the beginning of the criminal case to the sentencing of Dr. Richard Heartman, an internal medicine physician.

Billions are lost each year in Medicaid fraud. Finding the right attorney to guide you through

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

Insurers can refuse to pay claims or delete claims, deny or cancel coverage as well as underpay medical expenses. Fraudulent insurance companies can also collect premiums and pay for inexpensive care before disappearing if a large claim is filed. It has also been known for companies to look through insurer claims to intentionally drop them saying the insurer did not disclose previously.