The finance in health care is complex and it has different sources of spending healthcare money. Health insurance is one the “finance mechanism that protects the insure from using their personal funs when expensive care required”. (Nancy 214). Most of the people have insurance and the insurance covers their health care. For instance, Medicare is one of largest insurance that provides care to people who are 65 and older, people who are disabled and people who have end-stage renal disease. Medicare is “an entitlement program because people, after paying into the program for years, are entitles to receive benefits.”. (Nancy 215). Therefore, Medicare insures many elderly people. It is estimated that New Jersey is one of the states that has the …show more content…
Medicaid is a health insurance that provides people, with low income, health services. Medicaid is a state program that is funding by the federal government. This insurance is known to be one of the public financing of healthcare services. (Nancy 215). Also, it helps “45 millions of people” to be provided with healthcare. (Nancy 216). Medicaid is helpful to most of the low-income people living in the United states. However, it has been investigated that some medical staffs have been stealing from Medicaid. The government have created agencies in which helps in our days to investigate any abuse and fraud in the health care …show more content…
(1) . These takedowns were performed by the U. S Department of Health and Human Services and the Office of Inspector General. Also, the state and federal enforcement helped to find individuals responsible for medical schemes. The individuals who participated in these schemes were licensed medical professionals and doctors. (3) . The Office of Inspector General used the civil monetary law to penalized the guilty individuals for medical schemes. According to the 2016 National Health Care Fraud, "more than 60 licensed medical professionals were convicted for schemes. (3) . These schemes implicated " fraudulently billing to Medicare and/or Medicaid, ", charges for unnecessary services, charges for unneeded equipment, and other delinquent schemes. (4) . The fraud recorded, from July 2010 to June 2016, equivalenced to more than "3.5 billion dollars " of loss. (4) . Due to the
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...
What exactly is Medicaid? Medicaid is the largest health insurance in the United States, and it services many low-income families. This government health program is state regulated and varies among states due to having their own guidelines. Medicaid was signed into law on July the 30th, 1965. Medicaid’s guidelines come from the old Welfare law. “Medicaid has never matched that of food stamps, for which eligibility standards are linked to financial need alone. As Smith and Moore explains, the federal government, using its extraordinary demonstration powers under section 1115 of the Social Security Act, has allowed states to experiment with “decategorization” over the years, but Medicaid’s statutory bar against coverage of poor adults remains perhaps its most obvious failure” (Rosenbaum). Regardless of the many faults of this programs design, Medicaid helps close to 60 million low-income families in the United States. The people it helps would include: pregnant women, young children and their parents, the disabled, and the elderly, and other members of society that have low income. Medicaid is involved in many pregnancies and newborn care from a financial standpoint. It allows parents to have medical care for the child while in a low-income household. Medicaid has a huge impact on each states health systems and is used in a wide variety of ways.
Medicare and Medicaid are one of important government programs. According to Medicaid.gov site, there are more than 4.6 million low-income seniors enrolled in Medicare and about 8.3 million people that are enrolled in both Medicare and Medicaid. Anyone that enrolled with Medicare and limited income and resources are eligible to get assistance paying for their premiums and out-of-pocket medical expenses from Medicaid. Not only does Medicaid cover additional services, but, services covered by both programs are first paid by Medicare with Medicaid in the difference up to the state’s payment limit (Medicaid.gov, 2015) .
Implemented (along with Medicare) as a part of the Social Security Amendments of 1965, Medicaid’s original purpose was to improve the health of the working poor who might otherwise go without medical care for themselves and their families. Medicaid also assisted low income seniors with cautionary provisions that paid for the costs of nursing facility care and other medical expenses such as premiums and copayments that were not covered through Medicare. Eligibility for Medicaid is usually based on the family’s or individual’s income and assets. When the ACA came into effect in 2010, it began to work with the states to develop a plan to better coordinate the two ...
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.
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...
Medicare provides healthcare coverage for individuals over the age of 65, in addition, to others meeting certain criteria. The government funds Medicare through the administration of the federal Centers for Medicare and Medicaid and spends billions annually, on the program. Fraud runs rampantly throughout the healthcare program due to the enormous amount of money spent and the large number of people enrolled in the program. Fighting fraud of this nature necessitates diligence by everyone. Protecting oneself entails understanding what constitutes fraud, identifying it, noting suspicious practices, and taking steps towards prevention.
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)
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.
Medicaid is an assistance program for low-income people regardless of age. A federally mandated program, Medicaid is run by state and local governments under the established federal guidelines. Income and resource levels are the primary means for each state to determine eligibility with the level varying from state to state. Eligibility is also affected by other factors such as age, whether you are pregnant, if you are blind or have other disabilities, and U.S. citizenship or lawful immigration status. Some states req...
One in six Americans and mostly all of the population 65 years and older, are covered by Medicare. In 2012, Medicare provided for 50.7 million people, 42.1 million aged and 8.5 million disabled, with a total cost of $574 billion. This is about 21% of national health spending and 3.6% of Gross Domestic Product (Davis, 2013). Medicare, being a social insurance program, is required to pay for covered services provided to enrollees so long as the specific criteria is met. On av...
Levit, K. R., & Cowan, C. A. (1991). Business, households and governments: Health care costs, 1990. Health Care Financing Review, 13 (2), 83. Retrieved from: Ashford University Library
Under the Affordable Care Act one of the most important provisions is to expand health care to low income families through Medicaid. This could have an effect on over eight million people who do not have access to health care currently. However 25 states have decided against expanding Medicaid benefits, leaving 13.5 million people less likely to receive basic health care and preventative ...