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PubMed2001

The media's perspectives of health care fraud and abuse--an objective assessment.

The media make it seem that greedy health care professionals are perpetrating a widespread conspiracy to defraud the Medicare trust fund of billions of taxpayer dollars. However, the media often underreport another side to the health care fraud and abuse issue-the flawed, inordinately complex, and ill-equipped Medicare payment system itself. It is difficult to quantify the purported loss of billions of dollars to fraud or estimate the costs to the U.S. health care system of the advocated increased controls. However, this discussion serves to divert attention from key health care issues--the many Americans who are uninsured, underinsured, or lack access to care and the system's administrative complexities.

Diagnosis-Related Groups↗
PubMed1999

Home healthcare under fire: fraud and abuse.

Fraudulent and abusive practices in home healthcare are costly. They damage the integrity of the home health agency, the home care industry, and home care providers. Federal and state enforcement activities have increased exponentially over the past few years to fight fraud and abuse, resulting in the collection of nearly $1.1 billion in fines, settlements, and administrative impositions in 1997. This article discusses the issues of fraud and abuse and the responsibilities of home healthcare providers toward prevention and control of such practices.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1978

Fraud and abuse in psychiatric practice.

A consensus has not yet been reached on definitions of fraud and abuse, particularly the latter. Further, the terms tend to be linked routinely by federal agencies, although abuse is generally understood to relate to inappropriate and fraud to illegal practices. These definitional problems make it difficult to determine what constitutes fraudulent or abusive practice in psychiatry. The authors provide hypothetical examples relevant to psychiatry, noting that in many cases it is still impossible to determine at what point a practice becomes inappropriate or illegal. Criteria must be developed by claims review systems, ethics committees, and PSROs; all those in the mental health field should devote serious attention to these issues.

Crime↗
PubMed1990

Detecting health fraud in the field of learning disabilities.

Quackery is currently a widespread problem that pervades all aspects of healthcare, including the treatment of learning disorders. A discussion of the nature of modern health fraud in special education is presented. The psychopathology of health fraud, the standards by which pseudoscience and health quackery are defined, and the complexities of learning disorders are discussed. A Therapy Rating Scale to determine if an alternative therapy is reasonable is presented. Several popular therapies are used as examples.

Child↗
PubMedDate not supplied

Fraud-and-abuse enforcement in Medicare: finding middle ground.

Medicare fraud and abuse cost billions of dollars each year. Yet Congress is considering legislation to hamper enforcement. Providers' anger over enforcement led to a congressional compromise several years ago to limit excesses. If providers and their advocates were to hobble enforcement, this could provoke a backlash. Instead, the existing compromise should be strengthened to accommodate legitimate provider concerns while allowing enforcement against major fraud and abuse. Government should further confine, structure, and check its discretion in applying the False Claims Act. Enhancing the Health Care Financing Administration's capacity to ensure that contractors pay claims properly would remove additional points of friction.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1991

Medicaid fraud in New York State.

New York has taken a hard line on Medicaid fraud. Since its inception in 1975, the stat's Medicaid Fraud Control Unit has recovered more than $116 million in overpayments, fines, and restitution.

Aged↗
PubMed1992

Million dollar fraud: detecting, investigating, and preventing large-scale hospital theft.

Because hospitals often have large amounts of capital expenditures, they are particularly vulnerable to massive fraudulent schemes. Sometimes, the perpetrators are top-level executives, chief financial officers, or board members working in conjunction with outside contractors and suppliers. The losses can be devastating as witnessed by the recent uncovering of "Operation Catscam"--a large-scale x-ray scam, involving phony invoices, kickbacks, and outright theft of supplies, that operated for 14 years and bilked hospitals in New York and New Jersey out of at least $10 million. This report will detail recent incidences of massive hospital fraud: how the crimes were committed, how they were detected, the amount of loss involved, and procedures the institutions later put in place to prevent such thefts from recurring. In addition, we'll offer tips from investigative experts on how the security department can involve itself in helping to spot fraud early in the game and how to proceed with an in-house investigation.

Costs and Cost Analysis↗
PubMed1993

Fraud and abuse compliance programs: their time has come.

Two recent developments in Federal law enforcement should prompt healthcare providers to establish or augment programs to detect and prevent Medicare and Medicaid fraud and abuse. New and controversial Federal sentencing guidelines require judges to impose multi-million dollar fines on companies convicted of certain Federal crimes, and substantial civil monetary penalties may be imposed for violation of the Medicare and Medicaid fraud and abuse laws. One of the ways to avoid these penalties is to establish an effective compliance program designed to prevent criminal conduct before it happens.

Fraud↗
PubMed1994

Preventing banking and check fraud.

Most banking fraud involves disbursement activity which, by its nature, necessitates access to an organization's bank account. Banking fraud can be prevented by employing several internal controls and by using various banking products.

Accounting↗
PubMed1996

Health care fraud: a critical challenge.

Fraud is defined as an international deception or misrepresentation that the individual or entity makes knowing that the misrepresentation could result in some unauthorized benefit to the individual, the entity, or some other party. This article focuses on acts committed by health care providers but it is important to note that health care fraud also encompasses those fraudulent acts perpetrated by employer groups, members or insureds, and employees.

Capitation Fee↗
PubMedDate not supplied

Health care fraud: guilty until proven innocent.

During the summer of 1994, the special prosecutor for health care fraud of the Department of Justice (DOJ), Washington, DC, paid a visit to each of the US Attorney's offices throughout major metropolitan cities in America. Representatives of the American Hospital Association and the American Medical Association in Chicago were invited by the DOJ to meet with the special prosecutor and his assistant to discuss the implications of the DOJ's recent reassignment of health care fraud from its number 11 to its number two priority, second only to violent crime.

American Hospital Association↗
PubMed1997

Solicitation of new safe harbors and special fraud alerts--Office of Inspector General, HHS. Notice of intent to develop regulations.

In accordance with section 205 of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, this notice solicits proposals and recommendations for developing new and modifying existing safe harbor provisions under the Federal and State health care programs' anti-kickback statute, as well as developing new OIG Special Fraud Alerts. The purpose of developing these documents is to clarify OIG enforcement policy with regard to program fraud and abuse.

Fraud↗
PubMed1998

G-men. Federal resources are stacking up to tackle healthcare fraud.

Government fraud fighters are becoming as great a threat to providers as Treasury Agent Eliot Ness once was to mobster Al Capone. Federal agencies are packing heat with the False Claims Act in their fight against healthcare fraud and abuse. Last year the government collected more than $1 billion in fines and settlements. And observers say, for providers, the worst is yet to come.

Criminal Law↗
PubMed1997

Under the government microscope: how fraud and abuse allegations have taken the health care world by storm.

Hospitals are talking about it. Home health agencies are talking about it. Physicians are talking about it. The government and politicians are talking about it. And plenty of other people are talking about it, too. The subject is health care fraud and abuse, which often includes billing errors. As you may have heard, the United States Department of Justice has made fighting fraud and abuse within the nation's Medicare and Medicaid programs its No. 2 priority behind violent crime.

American Hospital Association↗
PubMed1998

Contingency arrangements do not necessarily equal fraud and abuse.

Many healthcare organizations avoid entering contingency-based arrangements with consulting firms that specialize in Medicare revenue optimization because they fear Federal investigation of such an arrangement might lead to a finding of fraud and abuse. A Medicare fraud alert issued by the HHS Office of the Inspector General (OIG) appears to justify that fear, suggesting that contingency arrangements are inherently unethical. Nonetheless, current Federal regulations clearly allow healthcare organizations to enter into contingency-based relationships with consulting firms to seek legitimate optimal payment. Healthcare organizations may do so without fear of Federal legal action if they ensure that the consultant is ethical and competent and that the DRG review process used is both legitimate and retrospective, subjecting all recommended changes to approval by both the healthcare organization and appropriate peer review organization.

Abstracting and Indexing↗
PubMed1998

Compliance plan can head off problems with Medicare fraud and abuse laws.

Don't assume that compliance issues are only for your Medicare managed care organization. Providers who don't understand how HIP AA and the BBA work together to hold providers and plans accountable for fraud and abuse can set themselves up for career-ending mistakes, experts warn. Here's how to avoid practices that could be considered Medicare fraud or abuse.

Aged↗
PubMed1987

Medicaid/Medicare fraud and abuse: practical guidelines for physicians.

Administrative and judicial interpretation of the Medicare and Medicaid Fraud and Abuse laws--particularly provisions on illegal referrals--pose a threat to physicians considering new business arrangements. This article sets out examples of arrangements likely to avoid claims of Fraud and Abuse and shows how certain modifications may substantially increase the risk of government charges of illegal referrals.

Crime↗