... | |Health Care Fraud and Abuse | | | | | |Tannisia Brown | |6/17/2012 | | | Health care fraud is the filing of dishonest health care claims to obtain a profit and is considered a white collar crime. Health care abuse is when someone overuses or misuse services. Both, Health care fraud and abuse, in the United States is an ongoing issue and is costing the United States government billions of dollars. Every time a fraudulent act is perpetrated the insurance company passes the cost to its customers. Due to the high volume of health care fraud statistics shows that 10 cents to every dollar spent on health care goes toward...
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...Running Head: Fraud and Abuse Fraud and Abuse in the U.S. Healthcare System Tenisha Howard Keller Graduate Professor Cutspec June 12, 2011 Background People can be affected by healthcare fraud and abuse directly and indirectly. Fraud is defined as an intentional deception, false statement or misrepresentation made by a person with the knowledge that the deception could result in unauthorized benefit to oneself or another person. It includes any act that constitutes fraud under applicable federal or state law. Abuse is defined as practices that are inconsistent with professional standards of care; medical necessity; or sound fiscal, business, or medical practices. Intent is the key distinction between Fraud and Abuse. An allegation of waste and abuse can escalate into a fraud investigation if a pattern of intent is determined (B, Tom). Both, fraud and abuse can be committed by physicians, patients, and private insurers. Situations of fraud and abuse that occur in our healthcare system are billing for services that have not been provided, overbilling for services provided, and misdiagnosing health conditions in order to avoid financial responsibility for the proper treatment of illnesses. Define the Problem What can decrease the high costs of premiums and co payments? With the decrease of fraud and abuse, premiums and co payments would not be high. Who pays for fraud and abuse healthcare bill? Medicaid and Medicare are the two federal programs that are...
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...A compliance plan is a program set up by the healthcare provider to ensure compliance with rules and regulations regarding coding and billing to prevent fraud and abuse. It is important for all staff members to be in compliance each and everyday because if a rule or regulation was broken even for the best intentions, the business as a group could be impacted negatively. Once the news has gotten out that your practice has broken the rules and regulations for being noncompliant then that could mean you may loose trust from your clients/patients and maybe seeking care elsewhere. You can potentially loose your business and have a bad reputation that may not recover from. How would you as a manager ensure staff members are serious about compliance?...
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...T ackling Fraud, Waste, and Abuse in the M edicare and Medicaid Programs: R esponse to the May 2 Open Letter to the Healthcare Community Dan Olson, CFE June 2012 Tackling Fraud, Waste, and Abuse in the Medicare and Medicaid Programs White Paper C ontents I. Introduction ............................................................................................................ 1 II. Recommendations................................................................................................... 3 Recommendation 1 – Expand the Medicare Fraud Strike Force Model....................................... 3 Potential Savings .......................................................................................................................... 4 Recommendation 2 – Expand Integrated Data Repository .......................................................... 4 Potential Savings .......................................................................................................................... 5 Recommendation 3 – Expand “Do Not Pay List” .......................................................................... 5 Potential Savings .......................................................................................................................... 6 Recommendation 4 – Publicize Drug Expiration Dates ................................................................ 6 Potential Savings ....................................................................
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...to any web site that collects personal information where they know that the information that they are collecting comes from children. Its basic provisions require that a "clear and prominent" link to the privacy policy must exist on the home page and that the privacy policy itself must be "clearly written and understandable." Furthermore, the legislation explicitly states what must be included in the content of the privacy policy -- this includes things such as the contact information for the operators of the page, the kinds of information that will be collected from children, how the information that is collected will be used, and information about what rights parents have to their child's information (Stanford). The Computer Fraud and Abuse Act (CFAA) is the federal government’s principal legal weapon in the battle to protect computer systems and electronically stored information from thieves and vandals. A criminal statute that can be enforced by the U.S. Department of Justice, the CFAA also authorizes private parties to bring a civil damages action against anyone who violates its terms. Two circuits have reasonably construed the CFAA in order to avoid an overbroad interpretation of its terms. Congress, however, may not be interested in clarifying the CFAA and instead may create new and needless ambiguity as to the meaning of its terms (Walser, McNeill & Zuckerman). Some courts have construed those terms quite broadly. For example, some courts have decided that...
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...Analysis of a U.S. Healthcare Challenge - Fraud and Abuse HSM 420 - Managed Care and Health Insurance April 19, 2015 Professor Bob Vega Critical Analysis of a U.S. Healthcare Challenge - Fraud and Abuse Introduction 2 What is Fraud and Abuse 2 Cost of Fraud 2-3 How can fraud be detected in Medicare 3 What are the implications for fraud and abuse 3-4 How can it be prevented? 5 Summary 6 Conclusion 7 References 8 Increasing costs of healthcare is a fear for many families in America. An issue in the rate of healthcare insurance is deception. Fraud is frequently very problematic to identify. The scale of healthcare fraud is indefinite. Preliminary compensation and expense and billing timeframe of 90 days permits for quick reimbursement of services, however, many times before there is a warning of deceitful billing the company has shut down and moved on. Fraud in American healthcare will cost American’s millions, possibly even billions of dollars each year. Without hesitation, behind every action of fraud, is an interval in ethics. Fraud is the deliberate dishonesty or falsification that a person knows to be untrue or that they consider to be factual is not, and sorts, if they know that the dishonesty might cause in an unsanctioned advantage to themselves or someone else. The most common kind of fraud rises from an untrue interpretation...
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...How Computer Fraud and Abuse Evolved Before 1984 there was little that could be done about computer fraud. In 1984 the Counterfeit Access Device and Computer Fraud and Abuse Act was the first legislation on computer fraud. The act made it a misdemeanor to illegally retrieve financial and credit information by computer. Also, the act made it illegal to cause harm to other computer systems. Around this time, what constitutes computer crime was still an ongoing discussion. As a Federal Act, only half of the states passed similar statues. (History of Computer Crime) The Computer Fraud and Abuse Act can be violated in two ways, either by an outsider trespasses into a computer or by someone on the inside who exceed their given authorization and go beyond their standard expectation. The first person who was charged for violating the Computer Fraud and Abuse Act was Robert T. Morris Jr. He caused harm to many universities and government computers by releasing a worm and was the creator of the first computer virus. He argued that he had only just exceeded his authorized access and not accessed the computers without authorization. To exceed authorization defined by the Computer Fraud and Abuse Act as “to access a computer with authorization and to use such access to obtain or alter information in the computer that the accesser is not entitled so to obtain or alter." The court found Morris guilty of acting without authorization. (Computer Fraud and Abuse Act (CFAA)) As the internet...
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...implemented to combat fraud and abuse in general was the False Claims Act of 1863. This act prohibits defrauding the federal government through the act of charging for services that were not provided, and gives the opportunity for whistleblowers to take action against those guilty of fraud and to receive a share of the money that is recovered. Amended in 1986, the False Claims Act had recovered $40 billion, and although this act was not specifically created for health care, half of these recoveries came from health care cases. Over 100 years later, the Social Security Act of 1965 imposed penalties on those who engage in improper conduct in a federal health care program and prohibited their further participation in these programs....
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...Search There are many cases that address the current critical regulatory issues in health care. Medicare fraud and abuse violations are only but one critical regulatory issue that is happening in America today. Medicare fraud and abuse is a major issue and it must be addressed. Many people today are lying on their applications in order to be approved for Medicare. This is hurting the people who truly need Medicare. Nature of Medicare fraud and abuse laws Medicare fraud and abuse is when someone will make false statements about themselves or that someone else is giving false information so the other person can get Medicare. When Medicare fraud happens it can either be a one person act or from a group of people or even an organization. Many people around commit fraud, in fact you may know someone who has already done so or may do so. “Organized crime is infiltrating the Medicare Program and masquerading as Medicare providers and suppliers” (Department of Health and Human Services, 2012). Some forms of Medicare fraud are: When someone is billing for services but there were no supplies that were available or services, when someone has billed Medicare for appointments that weren’t made, when someone changes claim forms or makes changes to receipts in order to get higher payments. Medicare abuse is when there is unnecessary cost in Medicare. “Abuse includes any practice that is not consistent with the goals of providing patients with services that are medically...
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...REPORT TO THE NATIONS O N O C C U PAT I O N A L F R A U D A N D A B U S E 2012 GLOBAL FRAUD STUDY Letter from the President & CEO More than 15 years ago, the ACFE’s founder and Chairman, Dr. Joseph T. Wells, CFE, CPA, conceptualized a groundbreaking research project to study the costs, methodologies and perpetrators of fraud within organizations. The result was the 1996 publication of the ACFE’s first Report to the Nation on Occupational Fraud and Abuse. Since then, we have released six additional Reports that have each expanded our knowledge and understanding of the tremendous financial impact occupational fraud and abuse has on businesses and organizations. We are proud to say that the information contained in the original Report and its successors has become the most authoritative and widely quoted body of research on occupational fraud. The data presented in our 2012 Report is based on 1,388 cases of occupational fraud that were reported by the Certified Fraud Examiners (CFEs) who investigated them. These offenses occurred in nearly 100 countries on six continents, offering readers a view into the global nature of occupational fraud. As in previous years, what is perhaps most striking about the data we gathered is how consistent the patterns of fraud are around the globe and over time. We believe this consistency reaffirms the value of our research efforts and the reliability of our findings as truly representative of the characteristics of occupational fraudsters...
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...on the need to eliminate unnecessary spending in health care--and among the leading candidates are fraud and abuse. Despite ongoing, concerted efforts, making meaningful inroads has not been easy."Fraud" refers to illegal activities in which someone gets something of value without having to pay for it or earn it, such as kickbacks or billing for services that were not provided. "Abuse" occurs when a provider or supplier bends rules or doesn't follow good medical practices, resulting in unnecessary costs or improper payments. Examples include the over-use of services or the providing of unnecessary tests. (Another area, "waste," refers to health care that is not effective, and will be the subject of a separate Health Policy Brief.)Endowed with new powers under the Affordable Care Act and the Small Business Jobs Act of 2010, the Centers for Medicare and Medicaid Services (CMS) has been adopting new tools to curb fraud and abuse in the Medicare and Medicaid programs. The new approach amounts to a paradigm shift from the earlier model, in which CMS paid providers first, then sought to chase down fraud and abuse after the fact--a process known as "pay and chase."This policy brief focuses on eliminating fraud and abuse in Medicare and Medicaid and explores the challenges involved in putting the new tools into place. | What's the background? | The true annual cost of fraud and abuse in health care is not known. In fiscal year 2011 Medicare spent $565 billion on behalf of its 48.7...
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...companies are truthfully reporting their financial solvency. In summary, the GAAP are responsible for ensuring that companies ethically record measurements at regular business intervals, prepare and summarize economic information in accordance to ethical standards, accurately measure economic activity, and truthfully disclose information about economic activity. Corporate compliance, ethics, or fraud and abuse Medical fraud and abuse in the healthcare industry is a rampant occurrence that significantly impacts not only healthcare in America but also the entire economy. Fraud and abuse within the healthcare industry can account for approximately 15 percent of annual expenditures. This represents up to $170 billion annually being lost because of fraud and abuse in the healthcare industry. Although the federal government has consistently passed legislation to fight against healthcare fraud, and committed millions of dollars toward preventing the abuse of Medicare and Medicaid by hospitals, doctors, and other healthcare professionals, less than 5 percent of healthcare losses from healthcare fraud are recouped by the federal government. Therefore, over a $100 billion a year is lost and never recovered as a result of healthcare...
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...Reporting Practices and Ethics Paper Reporting Practices and Ethics Paper Introduction In the health care industry organizations have to create guidelines and principles in order to successfully succeed. Implementing the four key elements of financial management and federally enforced principles are not enough. Ethics has also played a big role in the success of an organization. Many companies set up their own professional guidelines so that all employees maintain the same goal and success. However, as individuals every person has their own perception of personal ethics and sometimes can cause a struggle in certain workplace situation. Developing structure in an organization allows each department to operate to its fullest potential. In a health care organization the accounting department is considered the backbone of the organization. In accordance to, (Hicks, 2013) without an accounting department, it would be impossible for any type of organization to operate in a cost effective manner. The key elements of Financial Management There are four key elements that are recognized and implemented by financial management. The four elements are: Planning, Controlling, Organizing and Directing and Decision Making. An organization can become successful and accomplish goals by setting guidelines utilizing the element of planning. The second element used to succeed is controlling which ensures for all areas of an organization to follow previous planned goals and guidelines...
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...reasons is listed below as to why it is important to take action and take advantage of a full financial review. 1) The impact of occupational fraud and abuse on the company. Occupational fraud and abuse can financially damage a company. The term “occupational fraud” is defined as “The use of one’s occupation for personal enrichment through deliberate misuse or misapplication of the employing organization’s resources or assets.” There are three common types: Asset misappropriation (larceny, skimming); corruption (kickbacks, extortion); and fraudulent statements (financial statements, employment credentials)” (Akron/Canton, 2012). Without the knowledge of occupational fraud and abuse a company’s bottom line could be seriously affected. Not only does occupational fraud and abuse affect a company’s bottom line, but it can also affect employee morale, and customer loyalty. Undetected fraud and abuse can and has destroyed companies in the past and we as a company should make sure this does not happen. 2) U.S. governmental oversight of accounting fraud and abuse and its effect on the company. The United States government has implemented rules and regulations to handle occupational fraud and abuse. These rules and regulations come with penalties on companies and management personnel that have committed occupational fraud and abuse. In 2002 the United States government enacted the Sarbanes-Oxley Act of 2002, also known as the Public Company Accounting Reform and Investor...
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...Medicare Fraud: The History, Incidence, Costs and Institutional Remedies INTRODUCTION In 1965, President Lyndon B. Johnson signed the Medicare Act into law. The purpose was to provide healthcare to individuals the age of 65 or older or individuals under the age of 65 diagnosed with specific medical conditions (Center for Medicare and Medicaid Services, 2013). The original intent was to provide immediate payment to those providing medical services for the less fortunate. The Medicare Act has since been revised to meet the current needs of the American population as well as the United States economy. In part, these revisions included identifying, combating, establishing punishment (criminal laws) and prevention for Medicare Fraud. This paper will provide a brief overview of the Medicare fraud history, incidence, costs and institutional remedies. MEDICARE FRAUD: HISTORY AND DEFINITION Fraudulent activities against the government were first addressed during the Civil War. The False Claims Act (qui tam statute), also known as the Lincoln Act, was passed during this time frame. The intent was to prevent the Union Army from being a victim of supplier fraud. Citizens were given, “the ability to file suits on behalf of the US government whenever they spotted fraud” (Medicare Fraud Center, 2015). The citizens were rewarded with a portion of the monetary fines (issued to the defendant) for addressing the crime. Currently, similar rewards remain in effect for reporting Medicare...
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