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Medicare Fraud Essay

2952 words - 12 pages

Medicare Fraud: The History, Incidence, Costs and Institutional Remedies
John H Everett
Wayland Baptist

Medicare Fraud: The History, Incidence, Costs and Institutional Remedies
What is Medicare fraud? ("F&A," 2011, p. 1) states “Medicare fraud happens when Medicare is billed for services or supplies you never got. Medicare fraud costs Medicare a lot of money each year.” What is Medicare abuse? ("F&A," 2011, p. 1) defines this as “Abuse occurs when doctors or suppliers don’t follow good medical practices, resulting in unnecessary costs to Medicare, improper payment, or services that aren’t medically necessary.”
In reviewing the definitions of fraud and abuse ...view middle of the document...


With the rising cost of healthcare in the late 1980s and the continuing rising cost of it, many of the governmental fraud cases revolve around Medicare and other national healthcare programs like Tricare and Medicaid. Some of the key types of Medicare fraud are as follows: Incorrect billing, phantom billing, false certification, inappropriate services, bribing patients, charging for equipment and supplies which are never supplied, double billing involves charging for more than once for the same service, code jamming and upcoding.
One of the first big cases in Medicare fraud was with a company called National Medical Enterprises (NME) in 1994. The suit alleged patients rights were abused and NME settled for almost $600 million back in the middle 1990s. One of the conditions of the settlement agreement was NME had to sale of it specialty hospitals. NME later became to be known as Tenet Healthcare. In 2002, Tenet went through another fraud case with Medicare, this time they were charged with raising there charges by a large amount each year to reach Medicare outlier payments on a majority of its Medicare patients. This suit almost cost Tenet to go under as a business. Still today, Tenet is trying to recover almost nine years later from the effects of this case.
The largest in Medicare fraud involved a company called Columbia/HCA, now it is known just as HCA. The net settlement of the case includes the following: $631 million in civil penalties and damages, $840 million in criminal fines, civil restitution and penalties and $250 million to resolve overpayment claims arising from certain of its cost reporting practices. The total settlement for this case was $1.7 billion. ("HCA," 2003, p. 1) “This settlement marks the conclusion of the most comprehensive health care fraud investigation ever undertaken by the Justice Department, working with the Departments of Health and Human Services and Defense, the Office of Personnel Management and the states. The settlement announced today resolves HCA’s civil liability for false claims resulting from a variety of allegedly unlawful practices, including cost report fraud and the payment of kickbacks to physicians.”
This case started back in 1997 and took almost six years to complete. So, if one can imagine for the whole time your company’s name and reputation is publicized almost daily. Can you imagine the effect it had to each of its 300 hospitals? I can, fortunately or unfortunately I was with HCA during this time and I got to spend a lot of it helping various hospitals with subpoena requests. If you have ever since a good size board room full of boxes, it is very amazing and scary to look at. Also, to actually know some of the people who were charged and sentenced to jail, this will turn your world upside down. It was nice to find out all of these cases were over turned and the people were freed from jail, but still their lives, their families were totally...

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