Analyze a Contemporary Health Care Issue

Health care fraud and abuse are one of the U.S healthcare system biggest problems, which affect everyone either directly or indirectly. Billions of dollars have been lost due to health care fraud and abuse. With a number of losses, this can lead to increase in health care costs and potential increased of coverage.

Medicare and Medicaid have cause a great deal of damage to the American society. "Years of scandal have shown the waste, fraud and abuse that is rampant in Medicare and Medicaid." (Fallen Guardians of Justice: How the Supreme Court is

The American Health Care system needs to be constantly improved to keep up with the demands of America’s health care system. In order for the American Health Care system to improve policies must be constantly reviewed. Congress still plays a powerful role in public policy making (Morone, Litman, & Robins, 2008). A health care policy is put in place to reach a desired health outcome, which may have a meaningful effect on people. People in position of authority advocates for a new policy for the group they have special interest in helping. The Health care system is formed by the health care policy making process (Abood, 2007). There are public, institutional, and business policies related to health care developed by hospitals, accrediting organizations, or managed care organizations (Abood, 2007). A policy is implemented to improve the health among people in the United States. Some policies

Medicare and Medicaid fraud has some strengths as well as weaknesses. A strength that comes with healthcare fraud is The Affordable Care Act. This act helps to fight health care fraud, abuse and waste (Department of Human Services, 2014). Many laws have been implemented to help commit those people that have been committing Medicare and Medicaid fraud. Per the Center of Medicare and Medicaid services website “The Affordable Care Act increases the federal sentencing guidelines for health care fraud offenses by 20-50% for crimes that involve more than $1 million in losses, establishes penalties for obstructing a fraud investigation and makes it easier for the government to recapture any funds acquired through fraudulent practices” (Department

fraud risk exclusion from participation in Federal health care programs and the loss of their

Collectively, the Department of Health and Human Services and the Department of Justice work to reduce healthcare fraud and investigate dishonest providers and suppliers. The Health Care Fraud Prevention and Enforcement Action Team recouped almost 3 billion in fraud, this year alone. Also, aggressive strategies exist to eliminate Medicare prescription fraud. Patients abusing or selling painkillers received by visiting several doctors and obtaining multiple prescriptions costs Medicare millions annually. Fraud affects everyone, preventing it requires government officials and citizens diligently working together.

The newspapers are flooded daily with articles about medicare frauds and abuse, consisting of corrupt physicians, pharmacists,executives and at times even the whole institution maybe involved in frauds worth millions of dollars . It is very essential to figure out the structural and functional loopholes which the allows such large amounts of frauds (Rivlin,

New government statistics show federal health care fraud prosecutions in the first eight months of 2011 are on pace to rise 85% over last year due in large part to ramped-up enforcement efforts under the Obama administration. The statistics, released by the non-partisan Transactional Records Access Clearinghouse, show 903 prosecutions so far this year. That's a 24% increase over the total for all of fiscal year 2010, when 731 people were prosecuted for health fraud through federal agencies across the country. Prosecutions have gone up 71% from five years ago, according to TRAC. (Kelly Kennedy

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

Although Congress has used several anti-fraud measures to protect the federal government health care programs, the False Claims Act of 1986 has become the main weapon that government prosecutors use against perpetrators of health care fraud. Designed to prevent fraud and other abuses in federal government programs, the False Claims Act has been the primary statute the government has used in its fight against health care fraud. However, government prosecutors do not rely on one statute in their prosecution of alleged cases of health care fraud. Instead, they rely on a combination of statutes, but the False Claims Act has emerged as the main statutory weapon.

Throughout the year 2014 through 2015 many technology changes occurred to reduce the threat of healthcare fraud. Statistics show that healthcare fraud abuse laws help control cheating the system in the healthcare field. In 2014 68 billion dollars were spent on healthcare fraud, estimated by the national healthcare anti-fraud association. Others estimated that the cost could reach as much as 10 percent or 230 billion of the 2.27 trillion spent on healthcare fraud in 2015. With this coming to light to the health care administration and the U.S government. Healthcare fraud and abuse programs have been put in place to cut down this costly threat.

Health care fraud can affect everyone... including you. Certainly, only a small percentage of health care providers and consumers deliberately engage in health care fraud. However, even the smallest amount of stolen money from health care fraud can raise the cost of health care benefits for everyone noticeably. The healthcare system is a goldmine for fraudsters, scammers and organized gangs who have been stealing as much as $100 billion dollars a year. According to Louis Saccoccio executive director of the National Healthcare Anti-Fraud Association, he has stated ‘that healthcare identity theft dominated all other crimes in the sector of 2009(Medical, 1).

These crooks are the possible cause of ruining the reputation of the most trusted and appreciated professionals of our society – physicians. Healthcare fraud can be committed in a variety of ways, but three of the most widely used are described below. The first and most widely known, is billing services that were never endured by using general patient information. When giving personal information out, many hand it over to the front desk assistant at the local doctor. These appear to be people are some of the most known to scam the information and bill patient’s payments that never took place. Keep in mind that when handing over information, the handler is a trusted individual with a good reputation. On the other hand, many are scammed for the opposite; otherwise known as “upcoding,” where patients are billed more expensive services that were actually done. In fact, according to USA.gov a new study showed that 7 percent of identity fraud victims this year reported identity thieves stole their health insurance information, rising up from just 3 percent last year (Federal Bureau Investigation, 2010). This includes the latest scam, called “unbundling,” where scammers con bills and bill each step of a procedure as if it were a separate making the individual pay even more money, leaving devastating effects for the victim. All of which have a common goal of making taxpayers, insurance companies, and

Insurance companies and the federal government should pool resources using a percentage of profits to finance a task force to arrestively fight fraud. The penalty for fraud should be more stringent which will cause perpetrators to think twice before formulating a plan to commit fraud. The Affordable Health Care Act is the beginning of many programs established to fight against fraud. Health care fraud is a growing problem and should be taken more seriously by citizens of the United States. Physicians, health care workers, and patients are responsible for

Abstract— Fraud plays an important role in healthcare sector. It affects the whole system directly or indirectly. By increasing fraud in healthcare cost of treatments is also increased. It is calculable that some $700 billion is lost as a result of fraud, waste, and abuse within the USA healthcare system. Medicaid has been notably vulnerable target for fraud in recent years, with a distributed management model, restricted cross program communications, and a difficult-to-track patient population of low-income adults, their kids, and other people with certain disabilities. For effective fraud detection, one needs to cross-check the info on the far side the transaction-level.