Healthcare Fraud and Abuse

5 May 2017

Fraud and Abuse Abstract Rising costs of healthcare is a valid concern for many households in America. A factor in the cost of healthcare insurance is fraud. Fraud is often very difficult to detect. The magnitude of healthcare fraud is unknown. Initial reimbursement and payment and billing timeframe of 90 days allows for fast payment of services, however, many times before there is an indication of fraudulent billing the company has closed up and moved on. Fraud in American healthcare, costs American’s millions perhaps even billions of dollars annually.

Without doubt, behind every act of fraud lies a lapse in ethics. This paper will review several pieces of literature to look regarding healthcare fraud. It will discuss the different kinds of fraud, legislation used to combat fraud, a few settled cases, and lastly discuss ways to help to combat healthcare fraud. Fraud is the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the deception could result in an unauthorized benefit to himself/herself or another person.

The most frequent kind of fraud arises from a false statement or misrepresentation made or aused to be made, that is material to entitlement or payment under the Medicare program. The violator may be a physician or other practitioner, supplier of durable medical equipment, an employee of a physician or supplier, a carrier employee, a billing service, a beneficiary, or any other person or business entity in a position to bill the Medicare program or to otherwise benefit from such billing. Attempts to defraud the Medicare program may take a variety of forms.

Billing for services or supplies that were not provided Altering claim forms to obtain a higher reimbursement amount Deliberately applying for duplicate reimbursement in order o get paid twice Completing Certificates of Medical Necessity (CMNs) for patients not personally and professionally known by the provider Unbundling or “exploding” charges Soliciting, offering, or receiving a kickback, bribery rebate False representation with respect to the nature of the services rendered or charges for such services, identity of the person receiving or rendering the services, dates of the services, etc.

Filing claims for services that are non-covered but billed as if they were covered services Claims involving collusion between a provider and a beneficiary, esulting in higher cost or charges to the Medicare program Use of another person’s Medicare card in obtaining medical care Collusion between a provider and a carrier employee Any act that constitutes fraud under applicable federal or state law. NHIC Corp 2008) Fraud is a serious crime that should concern all parties of the U. S. health care system and is a costly reality that the government cannot overlook. While not all fraud can be prevented, by learning about the many different types of fraud, patients can be educated on how to protect themselves from fraud. There are ublic and a properly funded FBI will go a long way in the overall crackdown of health care fraud.

Although some of the practices noted above may be initially considered to be abusive, rather than fraudulent activities, they may evolve into fraud. When fraud has been committed, the government can: seek federal criminal conviction of the parties involved in the fraudulent activities; negotiate a civil settlement with the parties involved; take administrative action to exclude the responsible parties from the federal healthcare programs; suspend the provider from the Medicare program. (NHIC corp.

Federal law defines abuse, as applied to the Medicare program, as incidents or practices by providers, which although not usually considered fraudulent, are inconsistent with accepted sound medical, business or fiscal practices that directly or indirectly create unnecessary costs to the Medicare program. Improper reimbursement or reimbursement services, which fail to meet professionally recognized standards of care, or which are not reasonable and necessary are examples of such practices.

Abuse takes such forms as, but is not limited to: Over-utilization of medical and health care services; claims for services hat are not reasonable and necessary, or if deemed medically necessary, not to the extent rendered or billed; breaches of the assignment agreement which result in beneficiaries being billed for amounts disallowed by the carrier on the basis that such charges exceeded the Medicare Fee Schedule; exceeding the Limiting Charge for non-participating providers; violations of the Medicare Participating Agreements by physicians, suppliers or practitioners.

Many other forms of abuse exist and some, including those described above, are ultimately found to be fraudulent. When abuse s committed, the government can: Recover payment made in error; invoke civil monetary penalties congruent to the degree of abuse; suspend the provider from the Federal Healthcare Programs. (NHlC corp) The U. S. General Accounting Office estimates that $1 out of every $10 spent for Medicare and Medicaid is lost to fraud. This translates into fewer resources for health care due to the strains on federal and state budgets.

During FY 2005, the Federal Government won or negotiated approximately $1. 47 HIC, Corp. has an aggressive program to combat fraud and abuse, but need the publics help with reporting problems. Most providers of health are are honest businessmen and women who want to provide quality health care to Medicare beneficiaries. However, there remains a relatively small group of providers who take advantage of the Medicare program and engage in schemes or practices that result in inappropriate payments. At the crux of healthcare fraud is billing.

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Healthcare Fraud and Abuse. (2017, May 19). Retrieved June 7, 2020, from
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