What Is Healthcare Fraud?

Health matter, however, when the Act provide poor and/or low-income people with coverage that are as low as it can be with excellent benefits, people abuse it in way that sustain health problem. This result a serious health matter that can turn into a chronic illness or addiction, and cause complicated treatment that could cost a fortune to which is out of the Affordable Care Act coverage line. For example, a female driving a nice and luxury driving down the drive-thru to order her medicine with Medicaid coverage, what will the pharmacist think? Not only is this a fraud, but an abuse of the privilege received through the Affordable Care Act to obtain health insurance at a reasonably low price in order to maintain healthiness. This female have lied and continues to abuse this “authority” and purchase medicine that can worth hundreds of dollar.

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 goal of this deception is to obtain a federal healthcare payment that would not otherwise exist. The provider, practice, or institution may falsely claim to have provided a service or used supplies for a patient when in reality neither the service nor the supplies were used. A secondary way to commit Medicare fraud involves referrals. If one solicits, pays, or accepts money to encourage referrals because the services are reimbursed by Federal healthcare programs, they are participating in Medicare fraud. This type of fraud is addressed in the Anti-Kickback Statute. Lastly, Medicare fraud occurs when the complexity of services are overstated and billed at a higher than necessary rate. This action violates the False Claims Act which protects the government from being excessively charged for goods and services.

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

Healthcare fraud and abuse are substantial influence related to increasing health care cost. In the face of the seriousness of fraud and abuse offenses, increasing numbers of healthcare providers is pursuing new and more lucrative procedures to build business relationships. In the aspect of following an unsafe practice in order to receive kickback is uncalled for and serves as further investigation is necessary. OIG ‘s mission is to protect the integrity of the HHS programs and the health and welfare of the people

Health care fraud comes from many aspects. Fraud comes from some type of abuse to the system. Such abuse can come from billers, providers and or patients. Abuse of the system can turn into fraud. Because the fraud can come from many angles, it makes it really difficult for regulatory agencies to detect and protect against abuse and fraud. However, many changes to the system and the collaboration of regulations by many agencies have made a difference. Health care fraud is a crime that over time has had a significant impact on public and private health care payment system (Kongstvedt, 2013). Making a difference for this topic can have a significant impact on health care in general. Health care fraud takes a lot of means from the system, therefore affecting its goals. Not only does it distract the system from its objective, it also affects the financial status of the government. It takes a lot of effort to control fraud, economic effort that can otherwise be use in other struggles. Because this industry is one that grows with popularity, it is very difficult for only one organization to control or manage abuse or fraud. Popularity in this field brings great financial gains by those who choose to cheat or abuse the system. Above all, one must continue to make efforts to fight back and to control the losses caused by fraud. In order to continue these efforts, one must first understand how much is lost by these criminal acts. Therefore, this paper will focus on one

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

Healthcare fraud and abuse are different terms that describe different types of deceitful acts done by healthcare professionals or by solo individuals. Fraudulent medical billing is defined as knowingly submitting false statements or making misrepresentations of facts or false documentation to obtain a health care payment. These payments for which no entitlement would otherwise exist, knowingly soliciting, paying, and/or accepting compensation to encourage or reward referrals for items or services reimbursed by federal health care programs and making prohibited referrals for certain designated health services. Fraud healthcare schemes include

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:

Healthcare finances does not come without legal and regulatory issues. Issues in healthcare finances are false claims and whistleblower suits. The False Claims Act is a federal law that cover fraud in any federal funded program such as Medicare and Medicaid. This act covers knowing or conspiring to falsify any claim for payment by the federal government. In 2010 alone the government recovered over $7 billion in false claims, healthcare and pharmaceuticals made up 75% of total payment. And since then more than $130 million of claims has been settled.

Medicaid or ACA fraud can be conducted in a manner of ways, the most common seen are; Medicaid billed for services never done and equipment that was never used or was returned, d documents that were altered to receive higher payments, misrepresentation of dates, descriptions of furnished services, or the identity of the beneficiary, use of a person’s Medicaid card and ACA without the persons permission, and a company that uses false information to mislead someone into joining a Medicare plan (Collica-Cox, 2015).

The way that the Medicare system is set up makes it easy for people to commit fraud. The program was originally set up on a honor system. This system

Fraud is a serious crime that should concern all parties of the U.S. health care system and is a costly reality that the government cannot overlook. While not all fraud can be prevented, by learning about the many different types of fraud, patients can be educated on how to protect themselves from fraud. If we use government programs to inform the public that they can be targeted, the dollar amount for these cases for fraud can be reduced. An informed public and a properly funded FBI will go a long ways in the overall crackdown of health care fraud.

(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

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.