...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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...Medicare Fraud: The History, Incidence, Costs and Institutional Remedies John H Everett Wayland Baptist Medicare Fraud: The History, Incidence, Costs and Institutional Remedies What is Medicare fraud? ("F&A," 2011, p. 1) states “Medicare fraud happens when Medicare is billed for services or supplies you never got. Medicare fraud costs Medicare a lot of money each year.” What is Medicare abuse? ("F&A," 2011, p. 1) defines this as “Abuse occurs when doctors or suppliers don’t follow good medical practices, resulting in unnecessary costs to Medicare, improper payment, or services that aren’t medically necessary.” In reviewing the definitions of fraud and abuse by Medicare it may be hard for some people to understand if they do not live in the healthcare world daily. In an effort to help shed some light on this, we will look at the history of Medicare fraud. It has been around since the Civil War, when the False Claims Act (FCA) was created. It was also called the Qui Tam Statue meaning “he who sues for the king as himself.” ("FCA," 2011, p. 1) “The law was targeted at stopping dishonest suppliers to the military Union military at a time when the war effort made it all but impossible for the government to investigate and prosecute the fraud itself. Today it serves a similar purpose because of the enormous size of the federal government and the variety or programs under which it expends taxpayer funds.” In 1986 the FCA has been revised over the...
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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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...As a practice manager of a multispecialty practice, I’ve discovered that one of the internists has fraudulently billed Medicare through upcoding practices. Medicare fraud is a serious violation that comes with severe penalties. For instance, a physician paid over $100,000 in restitution to Medicare beneficiaries who he charged an annual fee for services already covered under Medicare (Lovette, 2011). In another incident involving false claim such as upcoding, a doctor was ordered to pay over $66,000 in restitution, sentenced to 5 months in federal prison, 5 months home detention with electronic monitoring, and 3 years of supervised parole upon release (Lovette, 2011). Physicians are held responsible for falsely reported claims. The government...
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...Dealing with Fraud Liquid Professor Beharry Health Care Policy, Law, and Ethics March 18, 2013 Abstract This paper will evaluate how the Healthcare Qui Tam affects health care organizations while providing (4) examples of Qui Tam cases that exist in a variety of health care organizations. Other responsibilities discussed, are devising a procedure for admission into a health care facility that upholds the law about the required number of Medicare and Medicaid referrals; the ability to recommend a corporate integrity program that will mitigate incidents of fraud and assess how the recommendation will impact issues of reproduction and birth. The know how to devise a plan to protect patient information that complies with all necessary laws. Evaluate how the Healthcare Qui Tam affects health care organizations. The Healthcare Qui Tam affects health care organizations in that well over more than 450 hospitals across the country were the subject of Medicare fraud investigations. Whether or not Medicare violations are found, the costs of responding to an investigation can be significant. Westchester Medical Center of New York, being investigated for possible health care fraud and violations of anti-kickback laws, received a subpoena for extensive records in some thirty-seven categories going back to 1997. Millions of dollars may be spent in legal fees and other costs associated with the investigation (e.g., hiring or reassigning staff to assist with compiling...
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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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...a long history. Reforms have often been proposed but have rarely been accomplished. In 2010, landmark reform was passed through two federal statutes enacted in 2010: the Patient Protection and Affordable Care Act (PPACA), signed March 23, 2010, and the Health Care and Education Reconciliation Act of 2010 , which amended the PPACA and became law on March 30, 2010. Future reforms and ideas continue to be proposed, with notable arguments including a single-payer system and a reduction in fee-for-service medical care. The PPACA includes a new agency, the Center for Medicare and Medicaid Innovation, which is intended to research reform ideas through pilot projects. ------------------------------------------------- History of national reform efforts Here is a summary of reform achievements at the national level in the United States. * 1965 President Lyndon Johnson enacted legislation that introduced Medicare, covering both hospital and general medical insurance for senior citizens paid for by a Federal employment tax over the working life of the retiree, and Medicaid permitted the Federal government to partially fund a program for the poor, with the program managed and co-financed by the individual states. * 1985 The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) amended the Employee Retirement Income Security Act of 1974 (ERISA) to give some employees the ability to continue health insurance coverage after leaving employment. * 1996 The Health...
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...Gross Domestic Product (ajronline.org, 2008). Hospital spending accounts for 31%, which is over the national health care expenditures. Physician expenditures are at 5.9%, and this is presently lower than the general expenditure amount due greatly to the 2% Medicare fee for physicians. Medicare Part D is at 19% and caused a quick rise in prescription drugs. Due to the high rate of individuals that joined the Medicare Advantage plan, administration fees were at 8.8% which grew faster than the overall. Due to the vast number of people enrolling in Medicare Part D, Medicaid shrank for the first time in history. The spending with health care is very high, and continues to climb. This means that the growth rates in health care persist to surpass the overall Gross Domestic Product, and will eventually exceed other spending. The national health care expenditures will not be supportable for the future health care system to run effectively or at all. There has been an adequate increase in Medicare Advantage which has made managed care more important at the present time putting the fee-for-service system at a danger. Fraudulent claims to Medicare and Medicaid are one cause of the high cost of health care today. Due to health care fraud the United States loses close to $60...
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...HMGT 6320.501 – The American Healthcare System, Briefing Paper- 2 Name: Dilpreet Singh What is Medicare? What are the components and how are they financed? What are the problems facing Medicare? What are your solutions? Medicare: Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant). Administered by the US government since 1966, Medicare is currently using 30 private insurance companies across United States. In 2010, Medicare provided health insurance to 48 million Americans—40 million people age 65 and older and 8 million younger people with disabilities. On average, Medicare covers about half (48 %) of the health care charges for those enrolled in Medicare. The enrollees must then cover the remaining approved charges either with supplemental insurance or with another form of out-of-pocket coverage. Components of Medicare: Medicare has four parts. These different parts help cover specific services. Medicare PART A (Hospital/Hospice Insurance): Part A covers inpatient hospital stays including semiprivate room, food, tests, care in a skilled nursing facility, and hospice care. (Hospice care focuses on palliation of seriously ill patient's pain and symptoms, and attending to their emotional and spiritual needs) Medicare PART B (Medical Insurance): Part B medical insurance covers certain doctors' services, outpatient...
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...is currently at $2.1 trillion. This translated into $7,026 per person and 16% of the Gross Domestic Product (GDP) (ajronline.org, 2008, pg. 1). 31% of this is for hospital spending, which is above the nationa health care expenditures. 5.9% for physician expenditures, which is currently lower than the overall expenditure rate due larglely to the 2% medicare fee for physicians. 19% for overall Medicare part D which caused a spike in prescription drugs. 8.8% in admisistravie fees, which grew faster than the overall rate because of the of the high number of members who joined the Medicare Advantage plan. Medicaid for the first time in history shrank because of the high number of people who enrolled in Medicare Part D. Heath care spending is to high and continues to grow, which means the health care growth rates continue to exceed the overall gross domestic product (GDP) and eventually will surpass other spending. This means that the national health care expenditures will not be sustainable for the future health care system to run efficentlty or at all. In the private sector Medicare has had a sufficent increase in Medicare Advantage...
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...OBAMACARE: The facts of the Patient Protection and Affordable Care Act Affordable Care Act (ACA), better known as Obamacare, is the president’s answer to the increasing healthcare costs. The purpose of this plan is to promise better quality healthcare at a more affordable cost to the Americans, and also regulate private insurance company to ensure Americans get more rights and protections on their healthcare. According to a 2012 study by The Kaiser Family Foundation (KFF), over 47 million non-elderly Americans were uninsured in 2012. Unsurprisingly, the majority of the uninsured are in the category of low-income working families. With the healthcare act being reform, there will be millions of uninsured Americans getting coverage for the first time. Additionally, Obamacare introduces Health Insurance Marketplaces (HIM)-a new organization that allows shoppers to compare Health Plans that include all new benefits, rights and protections. In another word, it also means the people can’t be denied health coverage based on health status, and can’t be dropped from coverage when they’re sick. Although millions of Americans will get access to health insurance with the healthcare act reform, the government has to create new taxes in order to get the money to help insure millions of them. The news taxes are as follow, Individual mandate fee, employer mandate fee, Advanced Premium Tax Credits, and Small Business Tax Credits. The individual...
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...Policy Process: The Affordable Care Act Dinah Riveron HCS/455 May 18, 2015 John Cutspec Policy Process: The Affordable Care Act The Patient Protection and Affordable Care Act signed by President Obama on March 23, 2010 as the means to enforce Health Insurance reform. Its main object is to make Health Insurance and Preventive care accessible and affordable to the American population. The Affordable Care Act The ACA major components include: Medicaid expansion, allowing states the opportunity to expand their existing Medicaid programs to include, (OPA, 1015) “individuals under 65 years of age with incomes up to 133% of the federal poverty level… (as well as) certain low-income adults without children” (Medicaid Expansion). Health Insurance Marketplace (HIM), available for access to individuals and small businesses enabling them to compare a variety of plans on the basis of price, quality and benefits and to choose the most affordable option according to their needs. The proposed three models are State Operated, State and Government Operated, and Federal Government Operated, for States that choose not to establish a program. Under the ACA, health services provided by all Insurance companies (participating or not on the HIM) are required to offer individuals and small businesses, affordable health Insurance plans that allow access to ten services identified as Essential Health Benefits (EHB). EHB services include, Ambulatory and Emergency services, Hospitalization...
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...and to provide insurance for more people in our country that could not previously afford or receive it. Since the Affordable Care Act has been passed, it has created uproar in our country. Many people in our Country do not want to be forced to purchase a healthcare plan created by the government, others don’t want to pay the increased taxes that have been enacted to help fund the new healthcare act. However, when it comes down to it, our healthcare system needed some change. The insurance companies had too much power; they could refuse to cover someone based on the most miniscule pre-existing condition. For the U.S. being the wealthiest country in the world, our healthcare was nowhere near the top in the world. There was a huge amount of fraud and waste going on in medical facilities across the nation, which was leading to increased unnecessary costs and overall inefficiency. The Affordable Care Act wont fix all of these problems right away or maybe even years down the road, but at least it is a step in the right direction and is putting methods into action to fix our healthcare system. The following policies are my three favorite policies of the Patient Protection and Affordable Care Act. One of my favorite policies of the Affordable Care Act is that it will prevent insurance companies from refusing you coverage because of most pre-existing conditions (Klein)(www.kff.org). This part of the new healthcare reform also prevents the insurance companies from turning down children...
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...Modern Health Insurance Model Health insurance has changed a lot over the years and will continue to change over time. There are many things to consider when looking at health insurance. Some of the aspects and terminology a person may need to inquire about when dealing with insurance would be group health insurance and individual health insurance. Individual health insurance “is a type of coverage purchased on the private market by a single person for themselves or their families.” (Contributor) It is meant to cover more than one person even though some mistake it for only one person because of the terminology “individual”. People whom normally purchase this type of insurance “don’t have access to group health insurance, can be denied, and will most likely be required to pay higher premiums due to age, gender, or any pre-existing medical conditions.” (Rowell, 2011) “Group health insurance is designed specifically for companies to buy for their employees.” (Contributor) This type of insurance is purchased on the open market just like individual health insurance but only by the employer not the employee. (Contributor) Another meaning for group health insurance is “traditional healthcare coverage subsidized by employers and other organizations (e.g., labor unions, rural and consumer health cooperatives) whereby part or all of the premium costs are paid for and/or discounted group rates are offered to eligible individuals.” (Rowell, 2011) When comparing and contrasting...
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...events. Include the following in your timeline: • Medicare and Medicaid • HIPPA of 1996 • State Children’s Health Insurance Program (SCHIP) • Prospective Payment System (PPS) |1960 |Prospective Payment System (PPS)- The mid-1960's brought about the view that access to| | |good quality health care could be provided for the U.S., regardless of ability to | | |pay. The PPS is a means to determine insurance payments for Medicaid plans. It is a | | |Medicare system that pays hospitals a set amount for covered diagnostic or treatment | | |services offered under Medicaid. | |1965 | | | | | | |Medicare and Medicaid- Medicaid is a federal program that provides insurance for low| | |income families. It is a program that was set up by the federal government and varies| | |from state to state. Medicare was created to deal with the high medical costs that | ...
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