Health Care Fraud

Health Care Fraud

Health Care Fraud

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Case Study: “Maryland Health Care Provider Sentenced to 10 Years in Federal Prison for Health Care Fraud Resulting in Patient Deaths.”

Read the news report “Maryland Health Care Provider Sentenced to 10 Years in Federal Prison for Health Care Fraud Resulting in Patient Deaths.”

Use the Five Whys to conduct a root cause analysis to determine why the Medicare fraud occurred and Timothy Emeigh’s participation in the case.

Write a 525- to 700-word paper that identifies and evaluates the root cause for Medicare fraud in this case.

Include the following:

• List each of the Five Whys and your response.
• Speculate as to why Mr. Emeigh participated in the scheme.
• Explain what you might have done to prevent this from happening.

Cite 3 reputable references to support your assignment (e.g., trade or industry publications, government or agency websites, scholarly works, or other sources of similar quality).

Format your assignment according to APA guidelines.

Recent news and statistics[edit]

The FBI estimates that Health Care Fraud costs American tax payers $80 billion a year.^[2] Of this amount $2.5 billion was recovered through False Claims Act cases in FY 2010. Most of these cases were filed under qui tam provisions.

Over the course of FY 2010, whistleblowers were paid a total of $307,620,401.00 for their part in bringing the cases forward.^[3]

Types[edit]

There are several different schemes^[4] used to defraud the Health care system.

• Billing for services not rendered
• Upcoding of services
• Upcoding of items
• Duplicate claims
• Unbundling
• Excessive services
• Unnecessary services
• Kickbacks
• Copied and pasted entries into the medical record^[5]

Billing for services not rendered[edit]

Often done as a way of billing Medicare for things that never happened. This can involve forging the signature of those enrolled in Medicare, and the use of bribes or “kickbacks” to corrupt medical professionals.^[4]

Upcoding of services[edit]

Billing Medicare programs for services that are more costly than the actual procedure that was done.^[4]

Upcoding of items[edit]

Similar to upcoding of services, but involving the use of medical equipment. An example is billing Medicare for a power-assisted wheelchair while only giving the patient a manual wheelchair.^[4]

Duplicate claims[edit]

In this case a provider does not submit exactly the same bill, but changes some small portion like the date in order to charge Medicare twice for the same service rendered. Rather than a single claim being filed twice, the same service is billed two times in an attempt to be paid twice.^[4]

Unbundling[edit]

Bills for a particular service are submitted in piecemeal, that appear to be staggered out over time. These services would normally cost less when bundled together, but by manipulating the claim, a higher charge is billed to Medicare resulting in a higher pay out to the party committing the fraud.^[4]

Excessive services[edit]

Occurs when Medicare is billed for something greater than what the level of actual care requires. This can include medical related equipment as well as services.^[4]

Unnecessary services[edit]

Unlike excessive services, this fraudulent scheme occurs when claims are filed for care that in no way applies to the condition of a patient, such as an echo cardiogram billed for a patient with a sprained ankle.^[4]

Kickbacks[edit]

Kickbacks are rewards such as cash, jewelry, free vacations, corporate sponsored retreats, or other lavish gifts used to entice medical professionals into using specific medical services. This could be a small cash kickback for the use of an MRI when not required, or a lavish doctor/patient retreat that is funded by a pharmaceutical company to entice the prescription and use of a particular drug.^[4]

People engaging in this type of fraud are also subject to the federal Anti-Kickback statute.