Due to the sheer volume of billing received each month, it is impossible for the system to review all the information before payment has been released to providers. This has led to a reactive approach in dealing with fraudulent transactions. Medicare database systems are not discovering fraud until after the fact and thus recovering funds can be challenging. As a result, over the last two decades, several legislations have been enacted to assist the Office of Inspector General (OIG) to investigate and prosecute offenders that have committed fraudulent billings against the taxpayer funded insurance system. The False Claim Act has been successful in prosecuting, collecting monetary sanctions from offenders. Furthermore, the Recovery Audit Contractor provides additional oversight of payments in specific vulnerable areas. The integrated data repository will allow access to files in one location for advance analysis to detect fraudulent claims. The enactment of stringent enrollment procedures should decrease the amount shell companies submitting payments for no services. Furthermore, utilization of forensic accountants should be employed to locate identity fraud within the Medicare system.
The False Claim Act (FCA) provides the statues to prosecute individuals that submit false information on their claim form. The FCA allows for both criminal and civil actions to be taken against the offender. These actions can be completed through the government or whistleblowers in qui tam suits. If whistleblowers engage in a suit and win, they are entitled to a monetary reward of 3-30% of the sanctions imposed by the courts (Golinkin II, 2013). Though the government can file a criminal investigation against an offender, frequently, a settlemen...
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...fferent sections. The FCA statues provide criminal sanctions but also the means of monetary recovery for the fraudulent acts. The RAC allows for greater scrutiny to claims in specific high fraudulent areas of supplies and home agencies. The OIG provide the necessary tools for providers to stay current on laws and common mistakes on claim forms.
Works Cited
Blank, S. M., Kasprisin, J. A., & White, A. C. (2009). Health care fraud. American Criminal Law Review, 46(701), 703-758.
Gingerich, B. S. (2009, April). National Recovery Audit Contractor (RAC) Program Expansion. Home Health Care Management Practice, 21(3), 208-210. doi:10.1177/1084822308327962
Golinkin II, J. W. (2013, July). Fishing with landmines: Healthcare fraud and the civil false claims act- Where we are, How we got here, and the case for more trials. American Journal of Criminal Law, 40(3), 301-325.
In the case of Tomcik v. Ohio Dep’t of Rehabilitation & Correction, the main issue present was the medical negligence demonstrated by the staff of the medical clinic at the Ohio Department of Rehabilitation and Correction towards the inmate Tomcik. Specifically, nonfeasance, or the “failure to act, when there is a duty to act as a reasonably prudent person would in similar circumstances” (Pozgar, 2016, p. 192), was displayed when the employees at the medical clinic failed to give immediate medical attention to Tomcik when she continually signed the clinic list and “provided the reason she was requesting
The Computer Fraud and Abuse Act (CFAA) of 1986 is a foundational piece of legislation that has shaped computer crime laws for the United States. It was spawned from Comprehensive Crime Control Act of 1984, Section 1030 that established three new federal crimes to address computer crimes. According to Sam Taterka, “Congress tailored the statute to three specific government interests: national security, financial records, and government property” (Taterka, 2016). The statue was criticized for the narrow range of issues it covered and vague language.
In July 2001 Robert R. Courtney’s illegal and highly unethical behavior was brought to the attention of local authorities and the Federal Bureau of Investigation (FBI). Courtney’s blatant disregard for the trust patients placed in him was evidenced by his daily violations of their rights and expectations while he supposedly provided quality healthcare service. By August 2001, following investigation, the FBI filed 20 federal charges against Courtney that carried a maximum prison sentence of 196 years (United Press International, 2002). $8 million of his assets which were estimated to be in excess of $10 million were frozen to be used as restitution for victims in the criminal case. Following a plea agreement Courtney’s prison sentence was pared down to 30 years and he and his company received a $15 million fine
One of the biggest contributors to health care costs that I have seen during my time in the healthcare industry is insurance fraud. One example of such fraud came about two months ago. I was taking a phone call from a provider that was upset that one of their claims had denied even though all of their previous claims had been paid. In researching with a partner plan it was determined that the claim denied because this medical provid...
During the 1980’s, medical-related situations continuously occurred that made patients question their insurance policies as well as the privacy of their health care. Congress worked to create a bill containing strict rules regarding insurance policies and availability for one to keep their insurance if they are to move jobs. These rules were soon applied to all medical facilities and faculty and titled the “Health Insuran...
3. Gillespie, Nick. "The Great Medicare Swindle." The Daily Beast [New York] 24 Oct. 2013: 1-3. Web.
As the lead prosecutor, the first fact that I would convey to my investigators is that the system was broken. Shipman was fired from the Todmorden Medical Center for forging prescriptions in order to support his addiction to pain medicine. He should have lost his medical license from the General Medical Council (GMC) and that would kept him from being able to practice ever again (Batty, 2005). Instead, the GMC only sent him a stern letter denouncing his actions, but allowed him to continue to practice medicine once he completed rehabilitation. As a result of the negligence of the GMC, anyone who ever looked into Shipman’s medical history, his forgery and addiction would not have been revealed by the GMC. Shipman resumed his medical profession in Hyde, England in which his patient’s high death rate came into question. The police failed to properly investigate the coroner’s concerns by not even running a criminal history on Shipman, which could have revealed his
Department of Health and Human Services. (2011, October 1). Protecting Medicare and You from Fraud. Retrieved December 10, 2011, from Medicare.gov The Official U.S. Government Site for Medicare: https://www.medicare.gov/Library/PDFNavigation/PDFInterim.asp?Language=English&Type=Pub&PubID=10111
"U.S. Judge Rules Health Care Reform Act Unconstitutional | Business Insurance." Business Insurance News, Analysis & Articles. Web. 20 Mar. 2011. .
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?
“Medicare and the New Health Care Law — What it Means for You.” (2010). Medicare Publications, http://www.medicare.gov/Publications/Pubs/pdf/11467.pdf
To gain a better understanding of the Federal False Claims Act, 31 U.S.C. §§ 3729-33, one must first consider when and how the law was established. According to the United States Department of Justice (DOJ) (n.d.), this law was first “enacted in 1863 by a Congress concerned that suppliers of goods to the Union Army during the Civil War were defrauding the Army” (p. 1). Since its original presentation, the law has been amended – significant changes were made in 1986, followed by three more ame...
Weld, L. G., Bergevin, P. M., & Magrath, L. (2004). Anatomy of a financial fraud. The CPA
Healthcare services have been on the rise for over 10 years now. According to a 2012 consumer alert, the industry provided $2.26 trillion in payments for more than four billion health insurance benefit claims in the year 2011(Fraud in Health Care). The bulk of the claims and the mainstream of fraud and abuse stem from the Medicare system professionals, who are knowledgeable about the process and persuade new clients into handing over their pertinent information in hopes of deception and illegitimate claims. Multiple and double billing, fraudulent prescriptions, are some of the major flaws in this organization that has made the healthcare services industry curdle. (AGHAEGBUNA, 2011) This is a non-violet crime and is often committed by very educated people including business people, hospital, doctors, and administrators.
Bakhurst, David. “Lying and Decieving.” Journal of Medical Ethics 18 (June 1992): n. pag. JSTOR. Web. 29 Sept. 2011.