Medicare Fraud - 2905 Words

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? (FA, 2011, p. 1) states â€Å"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? (FA, 2011, p. 1) defines this as â€Å"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†¦show more content†¦Some of the key types of Medicare fraud are as follows: Incorrect billing, phantom billing, false certification, inappropriate services, bribing patients, charging for equipment and supplies which are never supplied, double billing involves charging for more than once for the same service, code jamming and upcoding. One of the first big cases in Medicare fraud was with a company called National Medical Enterprises (NME) in 1994. The suit alleged patients rights were abused and NME settled for almost $600 million back in the middle 1990s. One of the conditions of the settlement agreement was NME had to sale of it specialty hospitals. NME later became to be known as Tenet Healthcare. In 2002, Tenet went through another fraud case with Medicare, this time they were charged with raising there charges by a large amount each year to reach Medicare outlier payments on a majority of its Medicare patients. This suit almost cost Tenet to go under as a business. Still today, Tenet is trying to recover almost nine years later from the effects of this case. The largest in Medicare fraud involved a company called Columbia/HCA, now it is known just as HCA. The net settlementShow MoreRelatedMedicare Fraud Essay988 Words   |  4 PagesDepartment of Justice work to reduce healthcare fraud and investigate di shonest providers and suppliers. The Health Care Fraud Prevention and Enforcement Action Team recouped almost 3 billion in fraud, this year alone. Also, aggressive strategies exist to eliminate Medicare prescription fraud. Patients abusing or selling painkillers received by visiting several doctors and obtaining multiple prescriptions costs Medicare millions annually. Fraud affects everyone, preventing it requires governmentRead MoreFraud Case Study : Medicare Claims1852 Words   |  8 Pages Fraud Case Study: Medicare Claims Carolann Stanek University of Mary Fraud Case Study: Medicare Claims False claims are a parasite to the American health care system resulting in overall higher health care costs. The Department of Justice reported recovering $1.9 billion dollars in fiscal year 2015 from fraudulent and false claims in health care (Department of Justice, 2015). In 2011, fraud and abuse were estimated to add $98 billion to federal spending for Medicare and Medicaid (FurrowRead MoreMedicare Fraud647 Words   |  3 PagesMedicare fraud is becoming a huge problem in today’s society. Medicare is a health insurance program for personnel paid by taxes the American population contributes to for personnel 65 years or older. When a health care provider, health suppliers, and private health companies deliberately bill Medicare for supplies or services that were not given is considered Medicare Fraud. To include, when a person uses another person’s Medicare card to receive health care for which the person does not qualifyRead MoreThe Senate Committee On Health And H uman Services1493 Words   |  6 PagesAlso, Charge VII: to monitor the implementation of laws addressed by the committee and make recommendations for improvement of any legislation in the sectors of Medicaid long-term care, Dental Board Reforms, Cancer Prevention and Research Institute, fraud, waste and abuse reductions of Medicaid and other health and human services programs in Texas (Governor, 2014). Other duties include Charge II: monitoring the implementation of programs to improve mental health and substance abuse services and makeRead MoreMedicare : Medicare And Medicaid1426 Words   |  6 PagesWeek 2 DB Billing 2 Compare and contrast Medicare and Medicaid; including funding sources, fraud and/or abuse, and eligibility requirements for recipients Both Medicare and Medicaid are administered through a division of Health and Human Services called the Centers for Medicare and Medicaid Services (CMS). CMS’s primary role is to monitor contractors and state agency to ensure the proper administration of Medicare and Medicaid. CMS establishes policies for the provider reimbursements, researchesRead MoreThe Impact Of Data Mining On The Healthcare Industry1451 Words   |  6 PagesData mining is used in various forms by different agencies. Detecting fraud and abuse is one of the benefits of the use of data mining. The healthcare industry is big and one of the biggest payers is CMS. However, detecting fraud and abuse in healthcare claims is crucial because billions of money is being wasted in unnecessary care. Data mining is defined as the process of data selection and studying and building models using massive data stores to disclose previously unidentified patterns in databasesRead MoreHealthcare Claims and Processing1600 Words   |  7 PagesA current LCD for the regional Medicare intermediary (Michigan - Region V) is shown in the example below. This LCD is for Erythropoiesis Stimulating Agents, L25211. The LCD is active and became effective on 12/1/2007 with an date of 11/01/2013 for the 10/22/2013 revision (cms.gov, 2014b). Question 8: Report on the Health Insurance Portability And Accountability Act (HIPAA) and its impact on healthcare claims processing. The Health Insurance Portability and Accountability Act (HIPAA) of 1996Read MoreSocial Security and Medicare Seeing Through Loopholes Essay1549 Words   |  7 Pages People receiving Social Security and Medicare need to prepare for drastic changes. Social Security and Medicare in unity has been around since 1965. President Lyndon B. Johnson decided to help the elderly pay for expensive medical necessities from doctor visits to medicine. President Johnson knew that elderly individuals would have less income and pay more for medical necessities than younger individuals. He made Social Security and Medicare a number one priority during his presidency, unaware yearsRead MoreThe Role Of Governmental Agencies On The Health Care Industry1271 Words   |  6 Pagesservices, perform studies, manage training, and technical assistance. Health Care Fraud Prevention and Enforcement Action Team (HEAT) The Department of Health and Human Services (HHS) and Department of Justice (DOJ) created the Health Care Fraud Prevention and Enforcement Action Team (HEAT). The (HEAT) collect information through the states to help avoid losing, fraud, and exploitation in health care programs such as Medicare and Medicaid. Chase on persons and associations who abuse the system which itRead MoreDelivering Health Care in America1726 Words   |  7 PagesCHAPTER 9 Medicare Enrollment â€Å"Ringing in the New Year with New Health Care Benefits† Some of the most important provisions of the Affordable Care Act will take effect in 2011. Starting this year, the vast majority of people with Medicare will see several new benefits, including free annual wellness check-ups, recommended preventive services without cost-sharing and discounts on prescription drugs in the Medicare Part D â€Å"donut hole† (Sebelius, Health Care, 2011). In addition, new rules will hold