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Fraud and Abuse in the U.S. Health Care System
Essay on health care fraud
Essay on health care fraud
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Recommended: Fraud and Abuse in the U.S. Health Care System
The definition of Health Care fraud is knowing and willful executing, or attempt to execute, a scheme or deceit to defraud a health care insurance or benefit program, or to obtain by fraudulent means any benefit or payment from the program. Health care fraud and abuse is purposely misrepresenting identity, symptoms, or other facts, for the intention of receiving more money or greater benefits from the insurance company. Healthcare providers can also commit fraud as well by billing insurance companies for services not performed, or by billing for a more complex service than was actually performed. There has been a rise in Healthcare fraud and abuse, causing companies billions of dollars.
Differrent types of Health Care Fraud include:
Fraud
Claims sent to the insurance companies could be rejected or denied. A health care facility is there to help people with their health, but they are a business that needs income to stay in business. If a medical facility or physician files a claim that is incorrect the Center for Medicare and Medicaid Services may get involved, this could mean audits, fines, or worse. Medical coding and billing are very precise and detailed work where mistakes can cause serious problems.
Sicko, a film by Michael Moore was released in 2007. The film investigates health care system in the United States. One would definitely get amazed by the facts and figures explained in this documentary. The movie explains failing health care system in the United States. America has advance medical technology, big hospitals, and educated health care professionals, but these facilities are not universal. The film starts by talking about true American stories; what some people have experienced from current health care system, those who had and did not had health insurances. The story starts by Adam, one of 50 million people in America who does not have health insurance. Due to an accident Adam required a medical treatment, but for the reason of not having any insurance he puts stitches on his leg by himself. The second story was about Rick, who accidentally cut the top of his two fingers, middle and the ring while working on the table saw. As a result of not having health insurance, Rick could not put the top of his middle finger back because it was costing 60,000 dollars and he did not had the money. So, he decided to put his ring finger back because it cost 12,000 dollars which he could afford. The movie does not go into the detail of 50 million people who do not have health insurance, but it’s about 250 million Americans who do have health insurance.
In the United States, healthcare fraud and abuse are significant factor associated with increasing health care costs. It is estimated that federal government spends billions of dollars on the health care cost (Edwards & DeHaven, 2009). Despite the seriousness of fraud and abuse offenses, increasing numbers of healthcare providers are seeking new and more profitable ways to build business relationships. These relationships include hospital mergers, hospital-physician joint ventures, and different types of hospital-affiliated physician networks to cover the rising cost of health care (Showalter, 2007, p 111-114). When these types of arrangements are made, legal issues surrounding the relationship often raise. There are five important Federal fraud and abuse laws that apply to the relationship and to physicians are the False Claims Act (FCA), the Anti-Kickback Statute (AKS), the Physician Self-Referral Law (Stark law), the Exclusion Authorities, and the Civil Monetary Penalties Law (CMPL) and (Office of Inspector General (OIG), 2010). Out of five most important laws that apply to the relationship and the physicians, we are going to focus on the Anti-Kickback Statute (AKS) and the Physician Self-Referral Law (Stark law).
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,
When one examines managed health care and the hospitals that provide the care, a degree of variation is found in the treatment and care of their patients. This variation can be between hospitals or even between physicians within a health care network. For managed care companies the variation may be beneficial. This may provide them with opportunities to save money when it comes to paying for their policy holder’s care, however this large variation may also be detrimental to the insurance company. This would fall into the category of management of utilization, if hospitals and managed care organizations can control treatment utilization, they can control premium costs for both themselves and their customers (Rodwin 1996). If health care organizations can implement prevention as a way to warrant good health with their consumers, insurance companies can also illuminate unnecessary health care. These are just a few examples of how the health care industry can help benefit their patients, but that does not mean every issue involving physician over utilization or quality of care is erased because there is a management mechanism set in place.
An issue that is widely discussed and debated concerning the United States’ economy is our health care system. The health care system in the United States is not public, meaning that the states does not offer free or affordable health care service. In Canada, France and Great Britain, for example, the government funds health care through taxes. The United States, on the other hand, opted for another direction and passed the burden of health care spending on individual consumers as well as employers and insurers. In July 2006, the issue was transparency: should the American people know the price of the health care service they use and the results doctors and hospitals achieve? The Wall Street Journal article revealed that “U.S. hospitals, most of them nonprofit, charged un-insured patients prices that vastly exceeded those they charged their insured patients. Driving their un-insured patients into bankruptcy." (p. B1) The most expensive health care system in the world is that of America. I will talk about the health insurance in U.S., the health care in other countries, Jeremy Bentham and John Stuart Mill, and my solution to this problem.
Health Maintenance Organizations, or HMO’s, are a very important part of the American health care system. Also referred to as managed care programs, HMO's are combinations of doctors and insurance companies that are formed into one organization. This organization provides treatment to its members at fixed costs and decides on what treatment, if any, will be given based on the patient's or doctor's current health plan. Sometimes, no treatment is given at all. HMO's main concerns are to control costs and supposedly provide the best possible treatment to their patients. But it seems to the naked eye that instead their main goal is to get more people enrolled so that they can maintain or raise current premiums paid by consumers using their service. For HMO's, profit comes first- not patients' lives.
What Seems To Be The Problem? A discussion of the current problems in the U.S. healthcare system.
Health care fraud is an ever growing problem with in our country. This is not a new issue, nor an issue that will ever go way. According to the Federal Bureau of Investigations (FBI) health care fraud cost tax payers two hundred and seventy two billion dollars in 2013 (Federal Bureau of Investigations, 2016). The numbers have continued to increase. When discussing health care fraud we need to know what exactly we are discussing.
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...
Health care fraud is the most important area to be analyzed as it put a great impact over US health care system. The reason behind the increasing cost is healthcare fraud. Increasing cost can be considered as the most visible factor in this term. US health care system is continuously using money over the health care system in order to make it better and protect patient from getting ill. Therefore, they have faced millions of challenges and for that they have spent more than 2.27 trillion dollars over the health care and 4 billion over health insurance. But these insurance claims turned about fraudulent (The Challenge of Health Care Fraud, 2014).
Healthcare is a complicated thing, but there are lots of things that need to be addressed. There is controversy about whether healthcare is a right, responsibility, or a privilege. This essay is going to explain examples of each. The word right can be defined simply as “something to which one has a just claim” (merriam-webster.com). According to the online legal dictionary, the word privilege is defined as “a special benefit, exemption from a duty, or immunity from penalty, given to a particular person, a group or a class of people”. Google dictionary describes responsibility as “The state or fact of being accountable or to blame for something”, or “The state or fact of having a duty to deal with something.”
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).