Whistleblowing In Health Care

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.

Illegal activity is something that we all have to aware of and careful to make sure we are not participating in. In the healthcare setting there are so many areas in which someone could attempt to something illegal. There are attempts, successful and unsuccessful, where patients, nurses, physicians, or anyone who is involved in the healthcare setting. As a medical assistant, any knowledge or signs of illegal activity should be reported. You should be able to provide evidence for the reason of accusation.

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).

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

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.

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.

It was amazing how the Northern Group practices came together as a family for this patient; not only were all of us in the administrative part of the office working on this case, but the office manager from Northern Pediatrics came out of her way to go through this complicated website to assist with the approval. I saw first-hand how these small town medical office personnel fought for this patient to be seen and how much they each cared, it was breathe taking. I’m not certain if the approval for care went through or not, but I do know that the patient received care with or without knowing how the services would be paid for. I did ask what would happen if Medicaid did not approve the services provided, without worry or concern of payment Gail simply stated that the office would have to write off the charges. How these offices communicated and worked together for this patient was like something from a book or movie. I have never seen such care and concern for a patient and all the energy poured into this lady’s well-being, it was truly amazing to

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 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 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

These providers would also bill for therapy sessions that were really just patient relocations, and billing for a glucose monitor that were not required, so it is easy to see why potential Medicare billing fraud is taken so

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).

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