Premium Essay

Health Care Fraud

In: Business and Management

Submitted By tallpaul85
Words 694
Pages 3
Insurance fraud occurs when any act is committed with the intent to fraudulently obtain some benefit or advantage to which they are not otherwise entitled to. Health insurance Fraud is becoming one of the top forms of fraud in America. Insurance fraud cost Americans billions of dollars every year as well as higher premiums. It is viewed as mostly a white-collar crime but it can come in many different forms. People who usually commit these kinds of frauds are motivated by greed for necessity or seeking wealth and luxury. There are several ways that healthcare companies are committing health insurance fraud. Examples of healthcare fraud include billing for services or supplies that were not provided, or billing Medicare for missed patient appointments, and altering CMS claim forms for higher payment amounts..

A successful prosecution of a health care provider that ends in a conviction can have serious consequences. The health care provider faces incarceration, fines, and possibly losing the right to practice in the medical industry. In Florida, it was reported that a physician was sentenced to 24 months incarceration and ordered to pay $727,000 in restitution fees for signing blank prescriptions and certificates of medical necessity for patients he never saw (Rudman, 2009). This is an example of the criminal liability that can result from healthcare fraud. In the case United States ex rel. Donigian v. St. Jude Medical agreed to pay $16 million to quiet allegations of paying kickbacks to physicians. The whistleblower was able to provide detailed insider information as to the nature of the kickbacks, which ranged from entertainment to sporting event tickets and other gifts. The relator in this case was awarded $2.64 million.

Congressional legislation requires that health care insurance pay a legitimate claim within 30 days. The Federal Bureau of...

Similar Documents

Premium Essay

Health Care Fraud

...Healthcare Fraud is when false information is promoted as the truth. The fraud could show in many forms, some as simple as billing for services that are not rendered. There are many types of fraud but some of the most common are billing for services not provided, billing for more expensive service not rendered, medically unnecessary services, misrepresenting services not covered by insurance to be medically necessary in order to receive insurance payments, falsifying a patients diagnosis to do unnecessary care or surgery, unbundling, and waving a co-pays or deductibles and overbilling the insurance company. No one really knows how much healthcare fraud is costing but the FBI estimates that it is around 80 billion a year and will continue to grow as healthcare cost rise. Healthcare fraud has become more prevalent with a lot of people. Health care fraud is not just committed by dishonest health care providers. “So enticing an invitation is our nation's ever-growing pool of health care money that in certain areas - Florida, for example - law enforcement agencies and health insurers have witnessed in recent years the migration of some criminals from illegal drug trafficking into the safer and far more lucrative business of perpetrating fraud schemes against Medicare, Medicaid and private health insurance companies.(NHCAA, Retrieved January 26,2014).” Healthcare fraud is not only being perpetrated by doctors, businesses but also many others such as drug dealers, and private......

Words: 579 - Pages: 3

Premium Essay

Health Care Fraud Feb 2011

...HEALTH CARE: SHOW ME THE MONEY By defining health-care fraud, observers should be aware that hard-earned money is wasted annually. Consequently, more precautions should be enforced to safeguard citizens’ tax dollars. Simply put, health-care fraud is the submission of false claims by individuals acting with disregard to the truth (Lovitky, 1997). Individuals, empowered to be health care providers, can be guilty of committing health care fraud, as well as major corporations (Sparrow, 1996). According to former Attorney General of the United States, Janet Reno, states health-care fraud ranks second of the top priorities of the Department of Justice, just behind narcotics interdiction (Lovitky, 1997). Health-care fraud typically involves violations by way of: overutilization; up coding; billing for services not provided; failing to provide necessary services; and filing false cost reports (Lovitky, 1997). Fundamentally, overutilization is defined as providing medical services not needed or required. In the process of overutilization, fraud takes place when more services are provided than what the situation calls for, or when medical services are never performed and still billed to the insurance company (Lovitky, 1997). Up coding, according to Lovitky (1997), involves Current Procedure Terminology (CPT). The CPT code accurately describes medical, surgical, and diagnostic services and it is designed to make medical services and procedures consistent among physicians,......

Words: 2023 - Pages: 9

Free Essay

N.Y Surgeon Sentenced in Multi-Million-Dollar Health Care Fraud.

...Abstract. Heath care fraud is a type of white-collar crime that involves the filing of dishonest health care claims in order to turn a profit. Health care schemes come in many different forms like: billing by practitioners for care that they never rendered, filing duplicate claims for the same service rendered, altering the dates, description of services, or identities of members or providers, modifying medical records, intentional incorrect reporting of diagnoses or procedures to maximize payment, prescribing additional or unnecessary treatment. In this paper, I will examine the Multi-Million-Dollar Health Care fraud that was committed by one surgeon, who worked in NY hospital. I will also apply the fraud triangle and go over detection and prevention steps. Introduction. Spyros Panos was a board certified orthopedic surgeon licensed to practice medicine in the State of New York. Between 2006 to 2011, Panos performed a huge amount of orthopedic procedures that helped him to make lots of money from his fraud schemes. He had back-to-back surgeries and had 12-hour surgery days. Most of the time Panos had two patients under anesthesia at the same time. He performed short operations and some of them were seven minutes long. (Nina Schutzman, 2014). The records showed the times of surgeries and administering of anesthesia but did not contain a description of the procedures or names of patients. Panos high volume of surgeries a day raised a red flag and......

Words: 1249 - Pages: 5

Premium Essay

Reporting Practices and Ethics Paper

...Reporting Practices and Ethics Paper Jessy Dominique-Clark HCS/405 Health Care Financial Accounting September 24, 2013 Debra Brindley Reporting Practices and Ethics Paper The National Health Care Anti-Fraud Association assess that the economic damages cause by health care fraud is more than ten of billon dollars every year. Financial controlling is difficult, but by using the four fundamentals of monetary management correctly and following the generally accepted accounting principles, revealing the financial position of an organization is not difficult ("The Challenge of Health Care Fraud", 2012). The four fundamentals of monetary management are controlling, decision-making, organizing, and planning. Controlling entails ensuring that every area of the organization is adhering to the plans that have been established. The decision-making process entails making an educated choice. Organizing entails using the organizations resources to successfully carry out the plans that have been established. The process of planning is to compile goals of the organization and then to identify the steps necessary for achieving these goals. The financial management team is accountable for ensuring the reports are up-to-date, and they are accountable for reporting the funds with the principles set forth by the code of ethics and mission statement of the organization. Every organization has the obligation and wants the veracity to release the correct financial position to its......

Words: 865 - Pages: 4

Premium Essay

Reportin Practices and Ethics

...Reporting Practices and Ethics xxxxxxxxx HCS/490 – Health Care Consumer: Trends and Marketing June 21, 2016 Professor Jack Heinen Financial management is a critical part of running and operating any business, and the health care industry is no different. In order for any health care industry to remain profitable and financially organized, it is extremely important for them to have someone designated to make sure that the finances are always current and monitored. It is also crucial that the organization utilizes the four elements of financial management. The four elements include planning, controlling, directing and organizing, and decision-making. Almost every industry that collects revenue sees some kind of financial fraud or abuse, and in the health care industry this has happened in many different ways. Making sure that there are accounting principles and ethical standards in place are an important way to try to avoid such chaos. The four elements of financial management are critical tools to help the financial manager keep a close eye on the finances from the start of a project to the very end. Planning is always the first element or step, and after assessing the business, the financial manager creates goals and objectives, based on the aims of the business. When making the plan, the financial manager will include the necessary steps to get there, what that will entail, and the end goal. Controlling is......

Words: 790 - Pages: 4

Premium Essay

White Collar Crime

...White Collar Crime Principles and Theory of Securities Management For: Professor Leiman By: Jaime Gwidt June 25th, 2016 Introduction This paper will cover the security crimes of credit card and health care fraud. It will discuss how these crimes are committed, their impacts on organizations and the tools a security professional has available to reduce opportunities for such crimes to occur. It will also cover an example of how credit card fraud was discovered and discuss possible measures that could have deterred those found guilty. Credit Card Fraud Credit card fraud occurs “when consumers give their credit card number to unfamiliar individuals, when cards are lost or stolen, when mail is diverted from the intended recipient and taken by criminals, or when employees of a business copy the cards or card numbers of a cardholder” (Chase, 2016). Credit card fraud is discovered by recognizing a break in spending patterns.  An example would be if you live in one area of the US and you have charges happening in another part of the states, that may tip the scales in favor of possible fraud, and your credit card company might decline the charges and ask you to verify them. Businesses and organizations are negatively impacted by credit card fraud. Small business is most negatively impacted. Targets won’t be happy about the massive losses, but small businesspeople can get destroyed. If fraudsters charge up a storm on stolen card data with a given merchant, and that......

Words: 862 - Pages: 4

Premium Essay

Reporting Practices

...accounting professionals must follow the ethical standards that regulate the type of business they conduct, who they conduct business with, and how they use their skills to conduct their business. These ethical standards are defined by professional finance organizations and the Financial Accounting Standards Board. This article will discuss reporting and ethical practices for any financial and accounting organization. It will include a summary of generally acceptable accounting principles and general financial ethical standards, as well as, summarize the four elements of financial management. This article will conclude by discussing researched articles on financial reporting practices, ethical standards, and financial management within the health care organization. Generally Accepted Accounting Principles (GAAP) and Financial Ethical Standards According to "Business News Daily" (2014), “Generally Accepted Accounting Principles (GAAP) is a combination of guidelines, comprehensive rules, and generally accepted standard practices utilized throughout the accounting industry to prepare and standardize financial statements, such as balance sheets, income statements, and cash flow statements” (Generally Accepted Accounting Principles (GAAP): Standards & Rules for Accountants). In 1999, the American Institute of Certified Public Accountants (AICPA) designated the Federal Accounting Standards Advisory Board (FASAB) as the most authoritative source of GAAP hierarchy for......

Words: 984 - Pages: 4

Premium Essay

Reporting Practice and Ethics Paper

...Reporting Practices and Ethics Paper Reporting Practices and Ethics Paper Introduction In the health care industry organizations have to create guidelines and principles in order to successfully succeed. Implementing the four key elements of financial management and federally enforced principles are not enough. Ethics has also played a big role in the success of an organization. Many companies set up their own professional guidelines so that all employees maintain the same goal and success. However, as individuals every person has their own perception of personal ethics and sometimes can cause a struggle in certain workplace situation. Developing structure in an organization allows each department to operate to its fullest potential. In a health care organization the accounting department is considered the backbone of the organization. In accordance to, (Hicks, 2013) without an accounting department, it would be impossible for any type of organization to operate in a cost effective manner. The key elements of Financial Management There are four key elements that are recognized and implemented by financial management. The four elements are: Planning, Controlling, Organizing and Directing and Decision Making. An organization can become successful and accomplish goals by setting guidelines utilizing the element of planning. The second element used to succeed is controlling which ensures for all areas of an organization to follow previous planned goals and......

Words: 1130 - Pages: 5

Premium Essay

Financial Practices

...Reporting Practices and Ethics Paper HCS405 July 29, 2012 Professor C. Brew Reporting Practices and Ethics Paper Financial accounting and financial management are the basis for health care accounting. The GAAP is a cornerstone of all accounting practices. Financial management aides and guides health care accounting practices in today’s health care settings. These two elements are the building blocks for a solid health care organization. Without the two, there is risk of fraud and unethical practices within health care. In financial accounting there are four elements of financial management. The first element is planning. In the planning element of financial management, the objective is determined and then the steps needed to reach that objective are identified so that the goal of accomplishing the objective can be met. The second element of financial management is controlling. In controlling the goals set in the planning element are monitored to ensure that the goal is on track. In the controlling stage of planning, managers use reports to track the goals, compare information and to gain feedback on the status of the goals. Organizing and directing is the third financial management element. In this element the manager works daily to track the progress of the goals, reviews daily the results of the organizing and is active daily in the progress of the goals. The final element of financial management is decision making. In the decision making element the......

Words: 1271 - Pages: 6

Premium Essay

Reporting Practices and Ethics

...Reporting Practices and Ethics HCS/405 Introduction Planning, controlling, organizing and decision making make up the four elements of financial management Baker (2011). Standards and guidelines of financial reporting are known as generally accepted accounting principles (GAAP) ("Accounting Principles & General Financial Ethical Standards", 2014). Financial ethics and standards determine the success of an organization. The VA is accused of the death of over 1000 waiting for care and budget mismanagement (“Bad VA care may have killed more than 1,000 veterans, senator's report says,” 2014). The alleged deaths could have been avoided through the use of GAAP. The FBI has uncovered millions of Medicare fraud rings (“More Than 20 People Arrested Following Investigations into Widespread Health Care Fraud in D.C. Medicaid Program ” 2014,). The Four Elements of Financial Management According to Baker (2011), the four elements of financial management are: planning, controlling, organizing and decision making. Planning is the stage of identifying the organizations objectives and steps to obtain the objectives. Controlling allows management to measure data from previous and current reports to determine changes within the organization as needed. Organizing is the stage in which management coordinates each aspect of the plan, such as; who, what, when and where. Decision making is management’s final role in making an educated decision based on the other four elements of......

Words: 1036 - Pages: 5

Premium Essay

Reporting Practice and Ethics

...Reporting Practice and Ethics HCS/405 Health Care Financial Accounting June 29, 2015 In order to function properly, every company or organization should have a financial plan in place. Health care organizations are part of the service industry and are no exception and cannot successfully operate without proper financial management. Financial management involves the managing of organizational funds in order to meet organizational goals and plays an important role in helping organizations work more effectively. According to Hicks (n.d.), “within accounting and financial management, there are four key elements recognized. The four elements are: Planning, Controlling, Organizing and Directing and Decision Making.” As with all other organizations, health care organizations must follow general ethical standards of conduct and financial reporting practices known as the General Accepted Accounting Principles (GAAP). The four elements of financial planning are set in place to help the financial process operate properly. The purpose of each of these tasks is as follows: * Planning - helps identify the organizational needs and objectives as well as the steps necessary to meet these needs; * Controlling – involves comparing current and past reports or feedback in order to determine if any area of the organization is ineffective or simply needs help. Controlling also ensures that the plans set in place during the planning process are being followed. * Organizing and......

Words: 735 - Pages: 3

Premium Essay

Obama Care Paper

...to help health care cost? The main cause for the healthcare reform bill is the rising cost of health insurance for the American citizens. From the 1960s to the 1980s healthcare spending went from $28 billion to $255 billion. By the beginning of 2000, healthcare spending increased to $1.4 trillion. The United States economy has slowly declined due to several factors, the cost of health care is one. Presidents, state representatives, hospital and insurance executives, and economists have tried to attack this huge deficit. There are several things that can be done in order to reduce rapidly increasing health care spending. Some actions that could benefit the United States economy is the stop of wasteful spending, create a team to control fraud, and give incentives to health care providers. Wasteful spending is one of the number one causes in health care cost. For years private insurers have relied on the police to focus on fraudulent people. Creating a team to focus of wasteful spending and fraud is a start in the right direction. There is wasteful spending within the hospitals, clinics and doctors’ offices. Medical fraud is also a problem that the team can focus on. Medical fraud can be fake claims, or payment schemes from doctors. Insurance executives should also be held accountable for their wasteful spending and unnecessary travelling. The money that is saved from wasteful spending can be given to the team for any resources that they need. Under the new health care......

Words: 1313 - Pages: 6

Premium Essay

Medicare Trust Fund

...2016 Charles gunter January 17, 2016 Charles gunter In 1965, United States instituted the most influential health program in our history. The Medicare and Medicaid program ensured that the aged, disabled, and poor had access to healthcare. The importance of a healthy society had finally made it to the mainstream and become a part of public policy. In this presentation, we will discuss the Medicare program. The Social Security Administration hosts the program and the “Centers for Medicare & Medicaid Services (CMS), a branch of the Department of Health and Human Services (HHS), is the federal agency that runs the Medicare Program” (Centers for Medicare & Medicaid Services, 2015). To enable these programs to work, funds must be allotted for services. The Medicare Trust Fund is one such vehicle. Currently, although suffering a few hits over the years, the Medicare Trust Fund has expanded and contracted through healthy and unhealthy periods (mostly healthy). Fortunately for the rapidly expanding American elderly population, the current state of the fund is promising. The fund has historically faced challenges and may continue to do so, but policymakers are faced with such a large aging (and voting!) population that the health of Medicare will always be top priority. Many factors that create challenge include fund solvency, fraud, and the growth of the population who fall within Medicare eligibility. Here we will discuss in more detail the Medicare......

Words: 1644 - Pages: 7

Premium Essay

Case Study

...Article or Case Law Search Article or Case Law Search There are many cases that address the current critical regulatory issues in health care. Medicare fraud and abuse violations are only but one critical regulatory issue that is happening in America today. Medicare fraud and abuse is a major issue and it must be addressed. Many people today are lying on their applications in order to be approved for Medicare. This is hurting the people who truly need Medicare. Nature of Medicare fraud and abuse laws Medicare fraud and abuse is when someone will make false statements about themselves or that someone else is giving false information so the other person can get Medicare. When Medicare fraud happens it can either be a one person act or from a group of people or even an organization. Many people around commit fraud, in fact you may know someone who has already done so or may do so. “Organized crime is infiltrating the Medicare Program and masquerading as Medicare providers and suppliers” (Department of Health and Human Services, 2012). Some forms of Medicare fraud are: When someone is billing for services but there were no supplies that were available or services, when someone has billed Medicare for appointments that weren’t made, when someone changes claim forms or makes changes to receipts in order to get higher payments. Medicare abuse is when there is unnecessary cost in Medicare. “Abuse includes any practice that is not consistent with the......

Words: 1159 - Pages: 5

Premium Essay

Reporting Practices and Ethics

...can ease the burden of comparing financial statements by using GAAP.  GAAP also aids in health care to establish creditworthiness of the business or organization and earn a rating of financial strength. GAAP allows business to use actual accounting. By using GAAP companies can report outstanding revenue. A company has the ability to show an acquisition or money that is guaranteed but not yet received, such as a government grant, which provides a higher net worth than if the cash accounting method were used. Monies defaulted by clients or patients is may not be included. This process is called a contra asset and is reported as a realizable value. According to the National Law Review, with the increased focus by the Obama Administration on financial crimes, health care fraud, and corporate fraud, corporate compliance and ethics programs have never been more important (2010). This article discusses the importance of effective corporate compliance programs and ethics programs. These Guidelines will help permit reductions of a subsequent sentence, culpability score, for organizations that have shown to have effective compliance and ethics program in place at the time of the offense, since 2004. This automatic reduction/credit will be inapplicable if high-level personnel in the organization condoned or willfully participated, or were willfully ignorant of the offense(s) (2010). Mismanaged care increases the risk for potential or real ethical issues. The American Nurses......

Words: 773 - Pages: 4