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In the past 5 years how has fraud and abuse affected the us health care system
Fraud and abuse in the healthcare system
Fraud and abuse in the healthcare system
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1. Medicare is a federally funded program that provides health insurance to Americans with end-stage renal disease, those at age 65, and younger people who qualify for Social Security disability benefits. It was initially passed as Part A (hospital care) and Part B (outpatient care) until the Balanced Budget Act of 1997 was created. Under this act, Part C (aka Medicare+Choice, now Medicare Advantage) combined A and B into a voluntary managed care program. Later, voluntary Part D was created, offering outpatient prescription coverage. Medicare expenditures increased from $4.2 billion in 1967 to $205 billion per year by 2000, $554.3 billion in 2011, and it’s expected to surpass $1 trillion by 2022. Medicaid provides free or low-cost healthcare …show more content…
The purpose of offering Medicare Advantage to Medicare beneficiaries was to offer prescription drug coverage without the beneficiary having to enroll in Medicare Part D. There is also a greater variety of healthcare plans/options with Medicare Advantage. Beneficiaries can choose between health maintenance organizations, preferred provider organizations, special needs plans, Medicare medical savings account plans, and private fee-for-service …show more content…
The major provisions of the ACA are to: expand coverage through public program and private-sector insurance expansions, reduce the rate of increase in Medicare/Medicaid spending, adopt several delivery system reforms, and improve workforce education with provided grants/loans. There are also provisions to: reduce waste, fraud, and abuse, impose new reporting requirements for tax exempt hospitals, and restrict the expansion of physician-owned hospitals.
6. Fraud is when someone tries to induce another’s reliance by intentionally misrepresenting fact(s). For example, when a healthcare provider intentionally bills for a service not rendered. Abuse is the unintentional misrepresentation of fact (i.e. unintentional billing/coding errors). There are statutes regarding fraud/abuse put into place by the government to control healthcare costs. Violations for both fraud and abuse are widespread and serious.
7. The government’s rationale for granting safe harbors is to ultimately protect physicians/certain healthcare plans (i.e. Health Maintenance Organizations) from being federally prosecuted under the Anti-Kickback Act. It identifies the safe and appropriate conditions under which payment practices should be conducted. Health centers need to be able to supplement scarce resources to underserved communities with the help from other providers, without fearing prosecution. There are safe harbors for several things, such as: investment interests, employment relationships, equipment
Membership Services (MSD) at Kaiser Permanente used to be a modest department of sixty staff. However, over the past few years the department has doubled in size, creating minor departmental reorganization. In addition the increase of departmental staffing, several challenges became apparent. The changes included primary job function, as well as the introduction of new network system software which slowed down the processes of other departments. These departments included Claims (who pay the bills for service providers outside of the Kaiser Permanente network), and Patient Business Services (who send invoices to members for services received within Kaiser Permanente). Due to the unforeseen challenges created by the system upgrade, it was decided that MSD would process the calls for both of the affected departments. Unfortunately, this created a catastrophic event of MSD receiving numerous phone calls from upset members—who had received bills a year after the service had been provided. The average Monday call volume had risen from 1,800 to 2,600 calls per day. The average handling time for each phone call had risen as well—from an acceptable standard of 5.6 minutes to an unfavorable 7.2 minutes. The department continued to be kept inundated with these types of calls for the two years that these changes have been effect.
(II) The enacting of Medicare Part D in 2006 only helped to fuel America’s hunger for prescription medication. In 2003, President George W. Bush announced and signed the Medicare Prescription Drug, Improvement, and Modernization Act (also known as the Medicare Modernization Act, or MMA) on December 8th. The roughly $400 billion dollar measure was marketed to the American public as something that will provide care for the millions of senior citizens who, at the time, were struggling to afford prescription medication. This was the largest development of Medicare since 1965, which is when the program was initially created, and gave hope to those wishing for positive medical reform. According to title XI of the “Medicare Prescription Drug, Improvement, and Modernization Act of 2003”, the most significant change will be the affordability of prescription drugs by implementing the importation of drugs from Canada, along with necessary safety measures, in order to lessen the cost (United States Congress, 832). For those who were in retirement homes and lacked a steady income, the affordability of drugs was often a deciding factor in the decision to seek medical attention and the idea that those individuals ceased to live simply because they lacked the funds tugged at the heartstrings of many Americans.
The Affordable Care Act or “Obamacare” was designed to assure that all Americans regardless of health status have access to affordable health insurance. The Affordable Car Act was signed into law March 23, 2010. The primary goal of this act was to decrease barriers for obtaining health care coverage and allow Americans to access needed health care services (Affordable Care Act Summary, n.d). After the legislation is fully implemented in 2014, all Americans will be required to have health insurance through their employer, a public program such as Medicaid and/or Medicare or by purchasing insurance through the health insurance marketplace exchange (Affordable Care Act Summary, n.d). I will identify three parts of The Affordable Care Act that I believe are important. First, I will talk about the requirement that insurance companies are no longer able to deny coverage to individuals with pre-existing conditions. Secondly, I will explain why physician payments are being shifted to value over volume. Lastly, I will discuss Medicaid expansion and why some states are not expanding at all.
The Health Insurance Portability and Accountability Act of 1996 was created to improve the efficiency and effectiveness of the health care system. There are numerous rules that fall under this act, which include Privacy, Security, Enforcement, Omnibus, and Breach Notification Rule. All of which set a national standards of protection, confidentiality, and integrity. HIPAA is to protect those who are patients in any medical facility.
In 2010, President Obama signed into law the Affordable Care Act in order to bring reform to the current healthcare system. The law was designed to provide healthcare coverage for people that did not have access to healthcare, improve the quality of the types of healthcare provided, and contain costs (HHS, 2014). Some of the features of the law are:
Fraud is putting the wrong information or up codding the codes on the claim form. This can be done by the doctor, biller and coder, and the patient selling their insurance number to false company. The false company can bill the insurance company, for false information whether it is services, medication,
Medicare is a social policy many of our seniors look to for their stability when they reach 65
Medicare is health insurance for people age 65 or older, under age 65 with certain disabilities and people of any age with End-Stage Renal Disease. There are four subcategories of Medicare. Part A is for hospital stays or, with certain restrictions, at-home care for a limited number of days. Part B is more like regular medical insurance. It covers ambulatory care and physician fees. There is a deductible and are sometimes co-pays as well. Part C is presented as an alternative to parts A and B. It is where private insurance companies can contract with the federal government to offer Medicare benefits through their own policies. It can offer benefits not covered under original Medicare, although there might be a premium charged. Part D is the prescription plan for enrollees. (Centers for Medicare and Medicaid Services, 2010)
Conditions of Participation was created to ensure all facilities participating in Medicare follow a set of regulations that protect the safety of Medicare recipients. In 1986 revisions were made to reinforce accreditation and certification procedures. Participating hospitals that are accredited by the Joint Commission on Accreditation of Healthcare Organizations or American Osteopathic Association have been deemed to meeting Conditions of Participation requirements on the wellbeing of Medicare Recipients. The Joint Commission on Accreditation of Healthcare Organizations also requires that the facilities are licensed by their state. (Lohr, 1990, p.
According to Medicare’s WebPage Medicare is a Health Insurance Program for people 65 years of age and older, some disabled people under 65 years of age, and people with End-Stage Renal Disease (permanent kidney failure treated with dialysis or a transplant). Medicare has two parts, Part A which is for basically hospital insurance. Most people do not have to pay for Part A. In addition it has a Part B, which is basically medical insurance. Most people pay a small monthly fee for Part B. Medicare first went into effect in 1966 and was originally administered by the Social Security Administration. In 1977 the control of it was switched over to the newly formed Health Care Financing Administration. Beginning in July 1973 Medicare was extended to persons under the age of 65 with certain disabling conditions. In 1988 Congress passed legislation to expand the program to cover health care costs of catastrophic illnesses.
Medicare was designed for beneficiaries sixty five years and older and enrollees who are permanently disabled and are unable to work. Medicare benefits are applied for at the Social Security office, where proof of eligibility is required. Medicaid however is health care benefits for those who are low income and do not have insurance through their job (Medicare.gov, 2008).
Health Care workers are constantly faced with legal and ethical issues every day during the course of their work. It is important that the health care workers have a clear understanding of these legal and ethical issues that they will face (1). In the case study analysed key legal and ethical issues arise during the initial decision-making of the incident, when the second ambulance crew arrived, throughout the treatment and during the transfer of patient to the hospital. The ethical issues in this case can be described as what the paramedic believes is the right thing to do for the patient and the legal issues control what the law describes that the paramedic should do in this situation (2, 3). It is therefore important that paramedics also
Medicare is the nation’s largest health insurance program. Generally, you are eligible for Medicare if you or your spouse worked for at least ten years in Medicare-covered employment and you are 65 years old and a citizen or permanent resident of the United States. Medicare-covered services include hospital insurance, inpatient hospital care, skilled nursing facility care, home health care, hospice care, and medical insurance (Medicare U.S.) With such an encompassing effect on the health insurance field, Medicare provides a haven for older individuals, and end-stage renal disease (ESRD) patients who require the best medical care for whatever possible reason. The only problem with this scenario is that doctors are turning many older patients away because they have Medicare. Why do doctors turn away Medicare patients? Is there a reason why certain doctors turn away certain patients?
Health care reform is needed for four reasons. First, health care costs are rising. In 2011, the average cost for a family of four increased 7.3%, to $19,393. By 2030, payroll taxes will only cover 38% of Medicare costs. Second, health care reform is needed to improve the quality of care. Because of these reasons, President Barack Obama signed The Affordable Care Act, also known as ObamaCare, into law on March 23, 2010 and upheld by the Supreme Court on June 28, 2012. The goal is to give more Americans access to affordable, quality health insurance, and to reduce the growth in health care spending in the U.S. The Affordable Care Act contains ten titles that span over 1000 pages, but most of its key provisions are in first Title; The first title is about 140 pages long. The purpose of the law if to expand the affordability, quality, and availability of private and public health insurance through consumer protections, taxes, insurance exchanges, and other reforms.
In March 2010, under the Obama administration, the United States enacted major health-care reform. The Affordable Care Act (ACA) of 2010 expands coverage to the majority of uninsured Americans, through: (a) subsidies aimed at lower-income individuals and families to purchase coverage, (b) a mandate that most Americans obtain insurance or face a penalty,