Healthcare Fraud and Abuse

Topics: Health care, Medicare, Health insurance Pages: 9 (3106 words) Published: September 30, 2010

Healthcare Fraud and Abuse

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 not personally and professionally known by the provider Unbundling or “exploding” charges Soliciting, offering, or receiving a kickback, bribery rebate False representation with respect to the nature of the services rendered or charges for such services, identity of the person receiving or rendering the services, dates of the services, etc. Filing claims for services that are non-covered but billed as if they were covered services Claims involving collusion between a provider and a beneficiary, resulting in higher cost or charges to the Medicare program Use of another person’s Medicare card in obtaining medical care Collusion between a provider and a carrier employee Any act that constitutes fraud under applicable federal or state law. (NHIC Corp 2008) Fraud is a serious crime that should concern all parties of the U.S. health care system and is a costly reality that the government cannot overlook. While not all fraud can be prevented, by learning about the many different types of fraud, patients can be educated on how to protect themselves from fraud. There are government programs to inform the public that they can be targeted. An informed public and a properly funded FBI will go a long way in the overall crackdown of health care fraud. Although some of the practices noted above may be initially considered to be abusive, rather than fraudulent activities, they may evolve into fraud. When fraud has been committed, the government can: seek federal criminal conviction of the parties involved in the fraudulent activities; negotiate a civil settlement with the parties involved; take administrative action to exclude the responsible parties from the federal healthcare programs; suspend the provider from the Medicare program. (NHIC corp.) Federal law defines abuse, as applied to the Medicare program, as incidents or practices by providers, which although not usually considered fraudulent, are inconsistent with accepted sound medical, business or fiscal...

References: False Claims Act, (Publication GAO-06-320R). Retrieved April 29, 2010
“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.
Posted January, 2010, Retrieved April 29, 2010
Qui Tam Action Law & Legal Definition
(2007). Health Care Fraud and Abuse Control Program Annual Report for FY 2006. Retrieved May 12, 2008, from
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