Healthcare Fraud and Abuse
Running head: HEALTHCARE FRAUD AND ABUSE
Healthcare 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 caused 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 to get paid twice Completing Certificates of Medical Necessity (CMNs) for patients
Healthcare 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 caused 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 to get paid twice Completing Certificates of Medical Necessity (CMNs) for patients
References: False Claims Act, (Publication GAO-06-320R). Retrieved April 29, 2010 from http://www.gao.gov/new.items/d06320r.pdf “Largest healthcare fraud settlements.” (2007, June 18). Modern Healthcare, Retrieved May 2, 2010, from MasterFile Premier database. NHIC CORP., A CMS Contractor Retrieved May1, 2010. http://www.medicarenhic.com/ne_prov/fraud.shtml Potter, Mark BATTLING THE MEDICARE FRAUD EPIDEMIC Posted January, 2010, Retrieved April 29, 2010 http://fieldnotes.msnbc.msn.com/archive/2010/01/11/2170075.aspx Qui Tam Action Law & Legal Definition (2007). Health Care Fraud and Abuse Control Program Annual Report for FY 2006. Retrieved May 12, 2008, from http://www.oig.hhs.gov/publications/docs/hcfac/hcfacreport2006.