Fraud Case Study Medicare Claims - 1852 Words

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 (Furrow, Greaney, Johnson, Stoltzfus Jost, Schwartz, 2015). It is the dollar figures like those listed above, that have necessitated the need for the Office of Inspector General [OIG]. The OIG has the authority to investigate and enforce penalties and†¦show more content†¦Herein, the violations of law governing Medicare, the possible penalties faced and by whom in this office, recommended actions for Sam to take, and safeguards the office may consider putting in place to prevent this from happening in the future in this specific case will be reviewed. Violations of Laws Governing Medicare Criminal Sanctions There are federal health care statutes that federalize fraud violations. A false claim violation includes knowingly making a false statement or representation of material fact or billing for services knowing that the individual that provided the service was not a physician and may warrant charges as a felony or misdemeanor (Furrow, et al., 2015). The Federal Criminal False Claims Act criminalizes knowingly making a false claim to the United States Furrow, et al., 2015). Criminal sanctions can also include aiding and abetting, conspiracy, and/or mail and wire fraud (Liebert-Hall, 2017). Criminal sanctions require proof beyond a reasonable doubt and proof of intent to defraud (Liebert-Hall, 2017). These laws are in place to promote positive and honest billing practices in health care. In the case study, there has been fraudulent activity in this office that would warrant criminal sanctions. There have been claims filed in which patients were seen by an NP but billed as though they had seen a physician, at times, even when that physician was not in the office that day. This is aShow MoreRelatedCurrent Health Care Issues1459 Words   |  6 Pagescontinues to rise each year. Health care fraud is a factor that continues to plague the health care industry. The affect health care fraud has on hospitals, is the increasing cost of medical services. 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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. If we use government programs to inform the public that they can be targeted, the dollar amount for these cases for fraud can be reduced. An informed public and a properly funded FBI will go aRead MoreEssay about Health Care Fraud2076 Words   |  9 PagesHealth Care Fraud: The typically overlooked crime of healthcare fraud has resulted in a significant monetary loss on the part of the American public paying into government run medical programs, as well as private insurance company programs. Historically, we have seen that in any instance where money is involved people have found ways to or at least have attempted to obtain it illegally. Some do it through overt acts of violence such as a robbery. 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