Healthcare Fraud

Topics: Health care, Health care provider, Health insurance Pages: 5 (1734 words) Published: October 16, 2013
On May 14, 2013 Attorney General Eric Holder and Department of Health and Human Services (HHS) Secretary Kathleen Sibelius announced “nationwide takedown” by Medicare Fraud Strike Force operations, in eight cities that resulted in charges against 89 individuals, which included doctors, nurses and other licensed medical professionals, for their alleged participation in Medicare fraud schemes involving approximately $223 million in false billings. In Chicago, seven individuals were charged, including two doctors, with a variety of health care fraud schemes. This (sixth) nationwide takedown targeted eight cities: Miami, Houston, Los Angles, Detroit, Tampa, Brooklyn N.Y, and Chicago. On April 16, 2013, the owner, senior executive of Sacred Heart Hospital, along with four physicians in the west side facility were arrested for conspiring to pay and receive illegal kickbacks. The kickbacks included more than $225,000 in cash, along with other forms of payment, in exchange for the referral of patients insured by Medicare and Medicaid to the hospital. On Oct 19, 2012, a west suburban dermatologist, Robert Kolbusz, was indicted in U.S. District Court on four counts of wire fraud and three counts of mail fraud. He was accused of submitting false claims for hundreds of patients, according to FBI officials. The Department of Health aand Human Services reported that in fiscal year 2011, in Illinois alone there were: 326 Medicaid fraud investigations, 48 were indicted on Medicaid fraud charges, 30 were convicted, 18 cases of civil settlements/judgments, and $47.8 million dollars was recovered in Medicare fraud cases. There are abundant news stories in the media today about the federal government enforcements against hospitals, laboratories, medical equipment suppliers, hospices, home health agencies, physicians and other health care service providers. Unfortunately, these cases are just the tip-of-the-iceberg with many health care fraud cases going undetected and or unreported. According to Black’s Law Dictionary fraud is defined as “some deceitful practice or willful device, resorted to with intent to deprive another of his/ her right, or in some manner to do him an injury. It is distinguished from negligence, and is always intentional”. Healthcare fraud is a white-collar crime that usually involves filing health care claims by healthcare service provider to turn a profit for the healthcare service providers. It involves “an unlawful act, generally deception for personal gain”, and encompasses a wide range of irregularities and illegal acts that are characterized by intentional deception. (Pozgar, 2011) According to the FBI (Federal Bureau of Investigations) healthcare fraud in our country costs an estimated $80 billion a year- making it one of the biggest “white-collar-crime”. Health care fraud is committed when a dishonest provider or consumer intentionally submits or causes someone else to submit false or misleading information for use in determining the amount of healthcare benefits payable. (Pozgar, 2011) Health care fraud usually includes insurance fraud, drug fraud and medical fraud. There are several ways by which the health care insurance fraud can be committed by fraudulent health care service providers: 1.) billing for services not rendered, 2.) up-coding of services which is billing the Medicare for services that were more expensive than the ones provided, 3.) up-coding of items which is billing for more expensive items than was provided, 4.) unbundling, wherein a corrupt healthcare service provides bills that stagger over time in order to claim more monies from Medicare, 5.) unnecessary services, 6.) duplicate claims- Medicare is charged twice for the same service and 7.) Kickbacks, which are rewards in cash or kind received by healthcare professionals for recommending or referring specific services for example referring a patient for an MRI even when it’s not required. The findings from the Office of Management...

References: Black’s free online law dictionary Definition of Fraud. (2nd Edition) Retrieved June 13, 2013
Blue Cross Blue Shield. Healthcare Fraud Regence. Retrieved June 17, 2013 from htttp://
Federal Bureau of Investigations. Healthcare Fraud. Retrieved June 14, 2013 from
Illinois Policy Institute
Kalb, Paul, E. “Health Care Fraud and Abuse”. Journal of American Medical Association 282 (1999): 1163-1168.
Price. Marilyn & Norris, Donna. Health Care Fraud: Physicians as White collar criminals? Journal of American Academy Psychiatry Law 37:286–9, 2009
Pozgar, George
US Department of Health and Human Services. News and Press Release. Retrieved June 13, 2013 from
US Department of Justice
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