The presented material for Unit 3 included three articles which discussed at length various aspects of healthcare related fraud, cited examples of Medicare fraud and also discussed preventative steps that can be taken to safeguard the economy from the effects of these frauds. In the first article, the Federal Bureau of Investigations (FBI) discusses the prevalence of healthcare related frauds and cites that expenses related to various frauds are anticipated to exceed $3 trillion in the year 2014 and have surpassed inflation related costs (Rooting out Health Care Fraud is Central to the Well-Being of Both our Citizens and the Overall Economy, n.d.). The FBI continues by identifying itself as the lead agency for investigating healthcare related …show more content…
The article continues by relating how individual cases of Medicare fraud are burdensome to both individuals as well to the economy as a whole. Examples of Medicare fraud are given and include cases in which an individual knowingly makes false statements, solicits either the paying or receiving of illegal funds or makes prohibited referrals which result in a false claim being filed (Medicare Fraud & Abuse, n.d.). Various examples of specific Medicare abuse are then cited and included types of improper payments which degrade the overall integrity of the program. Information is then given which regarded various laws that have been enacted to reduce the occurrence of false claim reporting and a detailed description was provided for each listed law. Separate and apart from the penalties prescribed under the listed laws, the article also explains actions which may be taken through the Office of the Inspector General (OIG). As explained, the OIG may utilize the Exclusion Statute and exclude an organization that has been found guilty of illegal practices, and/or the Civil …show more content…
In this specific case, an indictment was issues for the co-owners as well as two nursing employees by the Justice Department’s Criminal Division for charges ranging from healthcare fraud and conspiracy to commit healthcare fraud with each charge being applied to individual defendant and co-defendants in the case and quantified based on the individual number of offenses. Outlined in the indictments was evidence which supported that between January 2007 to September 2015, the defendants conspired to defraud Medicare by facilitating the submission and concealment of inaccurate Medicare claims (Dallas-Based Home Health Company Owners and Nurses Charged for Roles in %13.4 Million Medicare Fraud Scheme, 2015). The case hinges off of the individuals involved recruiting beneficiaries for home health services regardless of whether or not these services were appropriate and the preparation and filing of claims paperwork in support of these false claims. The article concludes by reiterating that all parties are innocent until proven guilty in a court of law, and states that since March of 2007 the Medicare Fraud Strike Force has charged nearly 2,300 defendants for fraud claims in excess of $7 billion (Dallas-Based Home Health Company Owners and Nurses Charged for Roles in %13.4 Million Medicare Fraud Scheme,
While working at the OB-GYN department in the hospital, Dr. Vandall, as a Vice Chair of the Department of Obstetrics and Gynecology, learned that another employee of the hospital, Dr. Margaret Nordell was engaged in a level of treatment that was unethical and violated accepted standards of care. It was his duty to the hospital and to the patients, to monitor the competence of his staff members. Although he tried to take the proper steps to deal with it within the hospital, he ended up reporting this to the North Dakota Board of Medical Examiners. It was concluded by the Board that the treatment of Dr. Nordell was gross negligence and they suspended her license to practice medicine.
(II) The enacting of Medicare Part D in 2006 only helped to fuel America’s hunger for prescription medication. In 2003, President George W. Bush announced and signed the Medicare Prescription Drug, Improvement, and Modernization Act (also known as the Medicare Modernization Act, or MMA) on December 8th. The roughly $400 billion dollar measure was marketed to the American public as something that will provide care for the millions of senior citizens who, at the time, were struggling to afford prescription medication. This was the largest development of Medicare since 1965, which is when the program was initially created, and gave hope to those wishing for positive medical reform. According to title XI of the “Medicare Prescription Drug, Improvement, and Modernization Act of 2003”, the most significant change will be the affordability of prescription drugs by implementing the importation of drugs from Canada, along with necessary safety measures, in order to lessen the cost (United States Congress, 832). For those who were in retirement homes and lacked a steady income, the affordability of drugs was often a deciding factor in the decision to seek medical attention and the idea that those individuals ceased to live simply because they lacked the funds tugged at the heartstrings of many Americans.
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).”
One of the biggest contributors to health care costs that I have seen during my time in the healthcare industry is insurance fraud. One example of such fraud came about two months ago. I was taking a phone call from a provider that was upset that one of their claims had denied even though all of their previous claims had been paid. In researching with a partner plan it was determined that the claim denied because this medical provid...
Fraud is putting the wrong information or up codding the codes on the claim form. This can be done by the doctor, biller and coder, and the patient selling their insurance number to false company. The false company can bill the insurance company, for false information whether it is services, medication,
Health Care Fraud and Abuse Control Program. (2003). Annual Report For FY 2002. Office of the Inspector General, U.S. Department of Health and Human Services website. Retrieved May 26, 2011, from http://oig.hhs.gov/publications/docs/hcfac/HCFAC%20Annual%20Report%20FY%202002.htm.
Medicare is a social policy many of our seniors look to for their stability when they reach 65
On December 8, 2003, President Bush signed into law the Medicare Prescription Drug Improvement and Modernization Act of 2003 (Pub. L. 108-173). This landmark legislation provides seniors and individuals with disabilities with a prescription drug benefit, more choices, and better benefits under Medicare. It produced the largest overhaul of Medicare in the public health program's 38-year history. The MMA was signed by President George W. Bush on December 8, 2003, after passing in Congress by a close margin. One month later, the ten-year cost estimate was boosted to $534 billion, up more than $100 billion over the figure presented by the Bush administration during Congressional debate. The inaccurate figure helped secure support from fiscally conservative Republicans. It was reported that an administration official, Thomas A. Scully, had concealed the higher estimate and threatened to fire Medicare Chief Actuary Richard Foster if he revealed it. By early 2005, the White House Budget had increased the 10-year estimate to $1.2 trillion.
Medicare and Medicaid together "are the single biggest contributor to [the United States] long term [budget] deficit." This idea was expressed by President Obama during his 2011 state of the Union Speech. After saying this, the president said that health care costs need to be reduced, including these two services. Medicare and Medicaid are beneficial to those who receive their services, and the criteria for eligibility currently allow many to qualify for either program. This is most likely the cause of the major deficit that the president spoke of. However, downsizing or eliminating these programs to lessen the deficit will affect many people and their ability to receive healthcare.
Medicare fraud occurs when healthcare providers, suppliers, and private companies charge for services or supplies patients never receive. Additionally, abuse of the Medicare program also occurs because physicians and suppliers do not always follow best medical practices which leads to excessive costs through improper payments, or medically unnecessary services, both of which abuse the program. Conservative estimates suggest he...
Medicaid is a broken system that is largely failing to serve its beneficiary’s needs. Despite its chronic failures to deliver quality health care, Medicaid is seemingly running up a gigantic tab for tax payers (Frogue, 2003). Medicaid’s budget woes are secondary to its insignificant structure, leaving its beneficiaries with limited choices, when arranging for their own health care. Instead, regulations are set in order to drive costs down; instead of allowing Medicaid beneficiaries free rein to choose whom they will seek care from (Frogue, 2003)
The two major components of Medicare, the Hospital Insurance Program (Part A of Medicare) and the supplementary Medical Insurance program (Part B) may be exhausted by the year 2025, another sad fact of the Medicare situation at hand (“Medicare’s Future”). The burden brought about by the unfair dealings of HMO’s is having an adverse affect on the Medicare system. With the incredibly large burden brought about by the large amount of patients that Medicare is handed, it is becoming increasingly difficult to fund the system in the way that is necessary for it to function effectively. Most elderly people over the age of 65 are eligible for Medicare, but for a quite disturbing reason they are not able to reap the benefits of the taxes they have paid. Medicare is a national health plan covering 40 mi...
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 the New Health Care Law — What it Means for You.” (2010). Medicare Publications, http://www.medicare.gov/Publications/Pubs/pdf/11467.pdf
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 educated people including business people, hospital, doctors, and administrators.