Medicaid Fraud: A Concern In The Medical World

1. A patient that complains about blood is his stool could use the CLIA waved test called Immunochemical Fecal Occult Blood Test. For the non-Medicare/Medicaid payers the test would be an 82272 CPT code and for the Medicare/Medicaid payers the test would be a Go434QW. Both of those test help detect why there is hidden blood in the stool.

In 2017, Nebraska installed a new program to better administer its Medicaid program. Since its launch, the system has left behavioral health and home health providers fuming over unpaid claims and frustrated about getting care authorized for patients (citation). Unpaid Medicaid claims topped $300,000 for one agency, prompting it to take out a line of credit for the first time in its 44 years and providers are worried about how long they can afford to keep seeing Medicaid patients (citation). Most of the problems being reported are among behavioral health and home health care providers, but others have experienced difficulties as well, including one rural hospital whose payment check from one of the Medicaid managed care companies bounced (citation). Patients are being severely affected, as they aren't taking the necessary medications because they aren't being authorized. In some cases, patients have had to extend their hospital time because therapy was also not being authorized in a shortly manner. Nebraska authorities have suggested that claim payments should speed up and that they problem will resolve in the

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

It is easy to see how fraudulent medical billing is having a major impact on the Unites States and the citizens of this country who rely on it on a daily basis. We often hear through the various new sources in this country, on the internet or out of the mouths of politicians and experts in the healthcare field about the failing healthcare system in this country. We often hear many different opinions on what needs to be done to fix our healthcare problem within this country and fix what looks to be a very broken system at this point. No matter what the solution to our poor healthcare system is one thing that is very clear is that healthcare fraud and abuse is playing a major role in the depletion of money in this country and the rise in healthcare costs for the citizens of this country.

There are several ways that both patients and healthcare providers can commit medicaid fraud. A healthcare provider can commit fraud by billing the insurance company for procedures that were never performed. Some healthcare providers bill people twice for the same procedure, and this is also considered fraud.

Medicaid has become an essential program for many, proving comprehensive inpatient and outpatient health care coverage, including many services and expenses Medicaid does not cover, especially, prescription drugs, diagnostic and preventive care, and eyeglasses. Medicaid can also help supplement Medicaid deductibles and premiums and pay a 20% portion of uncovered charges in some cases (Hansen, 2012). The program supports the country's most vulnerable and frail including children, those requiring long-term care services for chronic mental illness and retardation and those needing AIDs therapy (Goodman, 1991). These are enormous societal needs that may not be met without the assistance of Medicaid.

You’re sitting at home one afternoon, three weeks prior to the start of Open Enrollment, when you get a call from a friendly Center for Medicare Services (CMS) employee. The caller tells you that Medicare is issuing “new cards,” and that you need to provide your Medicare number, birth date and social security number in order to get yours. The catch? The caller doesn’t work for CMS, and he’s actually trying to steal your identity. Elder abuse is one of the most common crimes of the 21st century. In fact, studies have shown that 2 in 10 older adults have been financially exploited. Read on for 5 tips on avoiding common types of Medicare scams.

As Congress considers potential options to reform Medicaid, it is important to keep in mind patient access to prescription drugs and other healthcare services. Retail community pharmacies believe that Medicaid prescription drug benefit reform efforts should be focused on maintaining a Medicaid prescription drug benefit, maintaining patient access to adequate provider networks, fair and appropriate cost-based provider payments, and facilitating patient access to pharmacist-provided health care services.

Providing grants to health care facilities with Medicaid patients will enable these sites to conform with the goal. So your proposed idea of providing grants to small offices and rural hospitals needs to be considered. My cousin (he is a vascular doctor) opened an office in Florida and had to close it because payment issues with patients receiving Medicaid. As you can tell, Medicaid has limited budget therefore will affect those receiving Medicaid benefits.

Medicaid fraud, regardless of who perpetrates the fraud, is misrepresenting information to obtain a benefit from Medicaid. Both the state and federal government have programs to identify and prosecute Medicaid fraud, although, currently, the emphasis is on fraud prevention. Because fraud cost the Medicaid billions of dollars each year, these programs have become sophisticated; New York routinely checks DMV records, bank accounts and other data to discover potential fraud. Whistleblowers also receive money for reporting Medicaid fraud. Everyone who participates, in any way, in the Medicaid program may be charged with fraud including:

Medicare is national government run program that was developed in 1965. Medicare provides health insurance to Americans aged 65 and older who have worked and contributed to the program throughout their whole life by utilizing around 30 private insurance companies. The program also assists in providing benefits for younger people with disabilities. As well as offering Medicare in the United States a program called Medicaid is also available. Which is also a government run program, Medicaid is a state run program that provides hospital and medical coverage for people with low income (Medicare, 2015). With Medicaid being a state run program that allows each state to have different rules and regulations for who is and isn’t eligible as well as if they move across state lines. The programs listed above have helped many Americans over 65 and have a low income to be able to afford healthcare and receive the proper services for their healthcare concerns and issues. With any program and especially a government program there are going to be people who use and abuse the process which leads to Medicare and Medicaid fraud. There are many forms of fraud in Medicare and Medicaid such as billing for equipment or services that weren’t needed, falsifying health issues, dispensing generic prescriptions but billing for name brand. With there being so many types of fraud and investigations happening more and more due to the fraud that is occurring, people are finding more and more ways to

PPACA was initially envisioned to expand eligibility for Medicaid and Medicare. However, since Medicaid and Medicare are administered jointly through state and federal government, this provision could not take place after the Supreme Court determined that PPACA could not force states to expand their Medicaid program. The Court reasoned if states refused to expand their Medicaid program under the law, as it was written, then HHS would legally be entitled to withhold the state’s current Medicaid funding for non-compliance (Kaiser, 2015). Currently, an individual with an annual income that is within 133% of the federal poverty level is eligible for Medicaid, if living in a state that expanded Medicaid (Dixon, 2014). Under PPACA, the federal government

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

Fraudulent prescriptions are also on the rise. Physicians are writing illegal prescriptions that are billed for a claim for reimbursement, but have yet to see a bill of rendered services that called for the actual prescription. This often ends up happening to a patient who has little or no medical issues and has never been seen before. The provider who receives the forged prescription profits an anticipated amount of 15% to $20% in profits. (AGHAEGBUNA ,2011). There are four types of fraud that healthcare providers’ organization face. Patient fraud, provider employee fraud, provider billing fraud and payer fraud, even though providers need to receive payment for their service they should be more preventative action in place to ensure that these fraudulent activities can be detected.

In order to cover more seniors, states provide drug coverage in their expanded Medicaid programs. They take advantage of federal funds to uplift state resources. With the traditional Medicaid programs, states have to apply for medical waivers. If more seniors enroll in this Medicaid program, it increases significantly the states expenditure. The United States department of health and human services (HHS) announced plans to create a pharmacy waiver for seniors. The states under this special waiver can comfortably provide the seniors with a pharmacy waiver by taking advantage of the federal matching funds to provide service to the seniors who make a 200% of the federal poverty level.