Medicare Fraud

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Recommended: Strain theory introduction

In the United States, Medicare fraud costs the taxpayers approximately 60-250 billion dollars annually (Pande & Maas, 2013). Unfortunately, past steps to deter future criminality of this type of fraud have been fruitless. Similarly, identifying healthcare institutions and professionals that commit fraudulent acts are problematic; due to the differences of services provided to patients. An example, general practice doctors may submit a significant number of billings each month as opposed to an occupational therapist (Musal, 2010). Healthcare institutions may overbill for hospital stays that did not require admission in the first place. Regrettably, identifying offenders and institutions only clarify a portion of the issue. In addition, the need to know which theories can provide an explanation for why the criminal deeds are perpetrated. Essentially, the integration of both neutralization and general strain theories can provide an overall explanation to Medicare fraud.

Medicare fraud can be accomplished in several different ways by medical professional and institutions. In the past, medical professionals in the past have billed Medicare for treatments and equipment that are unnecessary. Overbilling for time not provided in the case of psychiatrists or physical therapists, or services not rendered to the patients at all. Evans and Porche (2005) survey concluded that over 81% of occupational, speech and physical therapists admitted to some form of Medicare fraud. Fraud can be merely cutting sessions short with clients but billing Medicare for the full time allotted or overcharging for their services. Healthcare institutions have admitted individuals when medically unnecessary. Similarly, many hospitals have submitted billing lacking...

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...t, C. S., & Jensen, G. A. (2013, April). Medicare payment generosity and access to care. Journal of regulatory economics, 44, 215-236.
Evans, R. D., & Porche, D. A. (2005). The nature and frequency of medicare/medicaid fraud and neutralization techniques among speech, occupational, and physical therapists. Deviant Behavior, 26(3), 253-270.
Langton, L., & Piquero, N. L. (2007). Can general strain theory explain white-collar crime? A preliminary investigation of the relationship between strain and select white-collar offenses. Journal of Criminal Justice, 35, 1-15.
Musal, R. M. (2010). Two models to investigate Medicare fraud within unsupervised databases. Expert Systems with Applications, 37, 8628-8633.
Pande, V., & Maas, W. (2013). Physician Medicare fraud: Characteristics and consquences. International Journal of Pharmaceutical and Healthcare Marketing, 7(1), 8-33.

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