Whistleblowing In Health Care

If a coworker is doing something illegal, you should report it to the physician. If it a patient who is doing something illegally, the physician should be notified as well as the local law enforcement. If the suspected or known illegal activity

Medicaid is a huge program that touches many lives but is nonetheless poorly understood by both the public and policymakers. Each state has the right to not participate in the Medicaid program, but Medicaid is one of the largest government insurance programs for individuals of all ages whose income and resources are insufficient to pay for health care.

Medicaid fraud comes in many forms. A provider who bills Medicaid for services that he or she does not provide is committing fraud. Overstating the level of care provided to patients and altering patient records to conceal the deception is fraud. Recipients also commit fraud by failing to report or misrepresenting income, household members, residence, or private health insurance. Facilities have also been known to commit Medicaid fraud through false billing. The Medicare and Medicaid fraud and abuse statute provides that an individual who knowingly and willfully offers, pays, solicits, or receives any remuneration in exchange for referring an individual for the furnishing of any item or service

Those who utilize the Medicaid system range from low income families to the over 65 age group. Within this population is also those who are disabled due to physical or mental problems. This is among the sickliest of our American population. A paper based on a study in Oregon stated that “Medicaid significantly increased the probability of being diagnosed with diabetes, and being on diabetes medication as well as high blood pressure and high cholesterol.”(Baicker et al., 2013, p. 1715). Much of this is due to the struggle that the Medicaid beneficiary has

Medicaid is defined as being a jointly funded state-federal health care program administered in Texas by the Health and Human Services Commission. Medicaid was established in 1967 and also stemmed from Patient Protection and Affordable Care Act P.L. 111-148 (Strategic Decision Support Team, 2010). Some of the goals and objectives within Medicaid are to make it less of a struggle for clients to get care, protects against out-of-pocket through the roof cost, and also to achieve cost savings for the state and federal government through the many improvements in coordination, as well as care (Eighty-First Texas Legislature, 1967).

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.

Medicare fraud is illegal and remedies are sought at both a civil and criminal level. If a provider, practice, or institution is found guilty of Medicare fraud, the consequences may include a loss of license, monetary penalties, and the inability to participate in Federal healthcare programs. The Office of Inspector General (OIG), which is a part of the U.S. Department of Health & Human Services, has the ability to exclude individuals who participate in Medicare fraud. The guilty party will be listed on a searchable database on the OIG website. The list is officially referred to as the List of

Medicaid is a federal and state program that helps with medical costs for some people who have a low income and limited resources. Medicaid is the largest source of funding for medical and health related issues in the United States. It provides medical care for nearly 60 million Americans (Medicaid History). Even though the program is joint between federal and state, the state decides how someone could be eligible for Medicaid.

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.

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

Medicaid is a health safety net program that was enacted to provide health care coverage to qualifying members of the population with low incomes and has become one of the largest payers for health care in the United States. In 2010, the Medicaid program was responsible for providing health services to over eight million women and covered over forty percent of all births. This gives Medicaid the distinction of being the majority payer for all maternity services in the United States.

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.

The ability to spread false billings among many insurers simultaneously, including public programs such as Medicare and Medicaid, increasing fraud proceeds while lessening their chances of being detected by any a single insurer.

Deciding to step up and report Medicaid Fraud is an honorable thing to do. It is also an action that while noble is not easy. While difficult getting a qualified, knowledgeable fraud attorney is the right course of action.

Sometimes before you know it you are trouble with Medicaid. When this happens, you need to have a lawyer to represent your interests. By the time you get the letter stating that you have committed Medicaid fraud, they already have all the information that is needed in order to indict you on criminal charges. You do not need to go into this alone. You need someone experienced in these types of cases. You need an experienced Medicaid fraud lawyer. A lawyer understands all the aspects of a fraud case and will be able to explain it all to you. If you go into his alone, you may find yourself in prison with a huge debt. A lawyer will help keep this from happening. While you may still have to do prison time and pay a fine the time in prison will