Healthcare Fraud

Introduction

For this particular paper, I have selected the topic of healthcare fraud. IN 1965, the Medicaid and Medicare programs were created in order to provide structured government mechanisms that would provide healthcare to the poor and elderly. Medicaid exists at the state level to provide healthcare to those who are unable to afford it (Reiman, 89). In all, over 36 million individuals receive healthcare through Medicaid. Medicare exists at the federal level to provide healthcare primarily to those 65 years of age and above, but also to vulnerable adults. Medicare is divided into Part A (providing hospital insurance) and Part B (providing medical insurance). Over 39 million individuals receive healthcare through Medicare (Payne, 32).

Physician Fraud

When public concern first surfaced about Medicaid/Medicare fraud, attention was directed toward activities by physicians, including doctors, dentists, psychologists, and other providers with practices in medicine (Dudek, 98). In the field of criminology, a host of researchers at the University of California, Irvine, were the first to discuss fraudulent activities by these medical professionals. Their research focused on the types of fraudulent acts committed, the system's response, and their causes. Researchers agree that several specific types of Medicaid/Medicare fraud have been committed by doctors (Payne, 95). Fee-for service reimbursement includes situations where providers bill Medicare or Medicaid for services that the client never received (Dudek, 99).

Pingponging entails instances where providers recommend that patients seek additional services from other providers when those additional services are not needed. This type of fraud generally involves several providers working in concert with one another. It is a little more difficult to establish than fee-for-service reimbursement because services are being provided, but it is not clear whether those services are needed (Reiman, 90).

Upgrading entails situations where providers submit bills to Medicare or Medicaid for services that were more expensive than the services that were actually provided (Constance, 19). Consider cases where dentists bill Medicaid for expensive fillings when they actually put in the cheapest filling possible.

Double-billing fraud entails instances where the provider bills more than one insurance company for the same services. There have even been instances when providers have billed patients and Medicare and Medicaid (Pontell, 83).

Studies show that psychologists and psychiatrists are somewhat over-represented in terms of fraud allegations. The explanation for this disparity lies in the ways healthcare is delivered and billed for by different medical professionals. When patients visit physicians, they are often unaware of the services they received. Consequently, it is difficult for investigators to determine if the medical bills were submitted improperly. It is easy for investigators to ask patients how long their professional spent with them. If the patient says the provider only spent five minutes with her, and the provider billed for an entire hour, then a crime has occurred (Payne, 33).

Prescription Fraud

In the mid to late 1980s, the healthcare field witnessed what was in effect a “war on physician fraud.” Investigations and prosecutions of these cases occurred more regularly than at any other time. In the early 1990s, the healthcare field witnessed ...