The War On Controlling Fraud And Abuse Essay

Rising medical costs are a worldwide problem, but nowhere are they higher than in the U.S. Although Americans with good health insurance coverage may get the best medical treatment in the world, the health of the average American, as measured by life expectancy and infant mortality, is below the average of other major industrial countries. Inefficiency, fraud and the expense of malpractice suits are often blamed for high U.S. costs, but the major reason is overinvestment in technology and personnel.

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

The rising cost of health care has led companies to stop offering health insurance for employees, and private insurance is often too expensive for people to afford. Many families make too much money to qualify for Medicaid, but are unable to pay for private health insurance. Health care costs in the United States have more than doubled in the last twenty years. Insurance premiums are rising five times faster than wages, and Americans are spending more money on health care than people in any other country. The average amount one person pays per year for health care in the United States is 134 times higher than the average of other industrialized countries (“Health Care Issues”). Even people who have insurance aren’t guaranteed coverage. Many insurance companies find loopholes to avoid paying for expensive medical treatment, leaving people with massive debt from medical bills. Medical bills and illness cause over half of all personal bankruptcies in the United

Health care has become a target for unscrupulous individuals. Both private industry and government are employing a variety of tools to combat fraud and abuse. Since 1992, we have made tremendous progress in protecting the fiscal integrity of the Medicare program. An example is the HCFA initiated partnership with the enforcement agencies targeting fraud and abuse in those five states that account for nearly 40 percent of all Medicare and Medicaid beneficiaries. This two-year project, Operation Restore Trust, encompassed a wide range of projects aimed at eliminating fraud schemes and identifying vulnerabilities in the Medicare programs. The reforms enacted in the Balanced Budget Act of 1997 and the Health Insurance Portability and Accountability Act of 1996 provide significant new tools to further assist us. But I think we all know that equally tremendous challenges he ahead. Our goal is to ensure that the Medicare and Medicaid programs have the necessary arsenal to combat fraud and

Some federal statutes address fraud in government health care programs, and many of these laws vary considerably (Krause 2004). Some of these laws specifically target health care fraud. Example of the laws that the government direct at inappropriate health care activities includes the “Medicare and Medicaid Anti-Kickback Statute and Ethics in Patient Referrals Act (EPRA).”

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

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:

(Jones and Jing) Though citizens might not see the effects of health care fraud directly, everyone is impacted in one way or another either through increased taxes, high insurance costs, or the inability to afford health care coverage. While we all hear about major frauds in the system, a majority of the frauds are small and usually go through undetected, unreported, or seriously underreported. (Sparrow) These small frauds add up to be a huge problem. There is a large spectrum of frauds in the health-care systems ranging from the theft of a wheelchair, to organized crime groups that steal patient information and bill for phantom services in multimillion-dollar schemes. (Jones and Jing) In many cases, the fraud is minor but all the small scams add up to an enormous loss to the public. For example, the frequent occurrences of forging of a doctor’s signature on a prescription accounts for billions of dollars lost each year. (Jones and Jing) One of the most common crimes involves billing for services that were never performed. This involves a health care provider submitting a false claim to be paid for a patient that was never treated or adding on services to a patient. For example a doctor may obtain names of other people such as a patients spouse or child who are covered by insurance and put in a claim for them as well as the actual patient. (FBI) Another common fraudulent activity involves upcoding of services. This is when a healthcare

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.

As the healthcare industry begins to expand its horizons, by featuring more staff and patients, the types of frauds that are committed also rise in number and complexity. One of the many consequences that derives from fraud within the healthcare system includes an increase in the cost of healthcare itself. In order to limit and analyze fraud that encompasses the entirety of the healthcare industry, it is necessary to assess the different types of frauds and in doing so also understand the method of reimbursement involving the professionals and members of the health care industry. Since a majority of these reimbursements are paid by insurances or through government programs, a program known as coding was created in order to organize and properly pay off these reimbursements(Marilyn Price, Donna Norris, 2009). One of the many

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

Insurance companies and the federal government should pool resources using a percentage of profits to finance a task force to arrestively fight fraud. The penalty for fraud should be more stringent which will cause perpetrators to think twice before formulating a plan to commit fraud. The Affordable Health Care Act is the beginning of many programs established to fight against fraud. Health care fraud is a growing problem and should be taken more seriously by citizens of the United States. Physicians, health care workers, and patients are responsible for

Combating fraud in the private sector is a difficult task. Trying to combat fraud in the public sector is daunting. In 1999 15.7% of the American workforce were employed by a government entity (federal, state, and local).[1] Mirroring society, government will have its share of perpetrators. The difference from the private sector is in the scope of the fraud committed, the loss of the public trust, the blaring headlines from news media, and difficulty in making necessary changes to combat the problems.