Medicaid Fraud and Influence on Medical Services

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Table of Contents

Introduction
Problem statement
How Medicaid Fraud occurs
Recommendations on how to prevent Medicaid Fraud
Implementation strategy
Consideration of success measurement techniques
Conclusion
References

Introduction

Medicaid Fraud is one of the main issues that hamper provision of quality, reliable, and efficient medical services across the world.

Medicaid is designed as a health insurance that offers the less fortunate in the society a chance to get affordable quality medical services; they are edible to children, the elderly, and persons with a disability and funded to a large extent by Department of Social and Health Services (DSHS) Medical Assistance Administration.

The United States government medical department with collaboration of the office of the Attorney General has been on the fore front fighting the vice; however, the vice seems to be far from being won. As much as the practice is unethical and unaccepted in the medical fraternities, the efforts that the federal government has enacted remain focused on corporate level but they seem to be un-reaching to the micro level practices.

According to Steven Malanga, the rate of misuse of Medicaid Fraud has continued to increase with an estimated amount of 10% of the total cost nationwide, which translate to about loss of &30 billion per year from the federal government.

Corporate compliance programs have focused on the corporate level but they have “allowed” the low practitioners like nurses, doctors and physicians to continue using Medicaid to defraud the economy. This leads to deteriorated economy or an economy with a huge medical bill to cover.

Although the program had been made to benefit the society and offer quality medical services across the board, it has been misused and defrauded for individual benefits (Matusicky & Cheryl, 1998). This paper discusses the problem of Medicaid Fraud and the interventions that federal and states governments should do to prevent the alarming state.

Problem statement

The main issue that is affecting the success of quality medical services to the less fortunate, children, and the elderly under the Medicaid program is fraud by medical practitioners for their benefits. The issue have an economic implication as the practitioners bill the U.S. Department of Health and Human amounts that does not commensurate with the service that they have offered to the patients or beneficiaries of the program.

How Medicaid Fraud occurs

Medicaid fraud takes different forms; however whichever the form they have some quality and financial implication to the beneficiary or the state government. The main ones are:

Unnecessary billed services

This occurs when a medical practitioner advices a beneficially of the program to undertake some medical services that are not really necessary; when doing this he or she is guided by the financial benefit that he will attain from the program.

This kind of fraud is technical and hard to detect especially with non-medical practitioners. For instance, a patient may call in a facility with a certain condition say Malaria, then the doctor or the medical officer advices him to undergo a full tests of some other related diseases like Typhoid, although the above advice may be agued to be for the good of the patient, the motive that the doctor has is ill.

None performed or are of a lower quality

In some facilities that get their funding and financial benefit from Medicaid programs have been accused of having fewer attendants than the ones that derive direct benefit from the program. With such a move then the state government pays for services that were not rendered. Another form taken by medical practitioners is offering low quality services to the patients and billing them highly.

When such an issue happens, the patient is left unattended while the practitioner gets unjustified financial benefit from the scheme. When patients get low medical services, the likelihood of demanding for more services in the near future is high making the burden even higher to the state government.

Prescribing costly programs

One issue that the sector has had is how to know the best amount to prescribe for a certain medication; there is no standard set rules that can be used as the governing or guiding pricing unit. With such a loophole, the practitioners have seen a system to exploit the government.

They may opt to bill very expensively, or prescribe some services that are overpriced so that at the end they will have more benefit that could be (Heeley & Whitley, 1998).

Purportedly covered items, which were not actually covered

When billing the department, the practitioners are expected to offer a list of the services that they offered to a particular patient; the document is needed to have been signed by the patient in question or a caretaker.

What the practitioners are doing is to ask the patient sign the document before they have been attended, then after attending them, they are left indicating the areas that they covered, and this is the point that they include some services that they never provided to the patient.

This is formulae of exaggerating the medical bill to the loss of the state government.

Recommendations on how to prevent Medicaid Fraud

The issue facing the health care sector can be prevented and managed if stakeholders can combine their efforts and powers in that effect. The main stakeholders in the prevention program should be the government (through ministry of health and the office of the Attorney General), professional bodies, the practitioners, and patients (Meulemans, 2011).

The government

The government was the one that made the program a success and it is the one that collects taxpayer’s funds and uses them in the sector, thus it should be in the forefront in providing leadership to prevent fraud.

The government should install high-powered fraud-tracking computer programs to assist in getting the perpetrators of the illegal practice; such programs should be able to detect the risk areas and post audit the services that have been offered by the practitioners.

The systems should be strong enough that they can prevent the intervention of unscrupulous licensed practitioners who have continued to defraud the system; it should be able to maintain sanity I the sector as well as reduce the chances of growth of such practices.

So far, there are some states that have not yet criminalized the practice making it a green area that practitioners can use to benefit themselves; the “watchdogs “ that have been used have played the role without enough legislative powers to prosecute those practitioners who have defrauded the system. This should be changed and have they empowered for the good of the sectors.

When developing the penalties and punishments to be given to fraudsters, the state should support harsh punishments that are likely to deter them from defrauding in the future as well as threaten others who had such a thought. The penalties should be extended to the professional body that the fraudster comes from in the efforts of asking them to be more vibrant and careful with their members.

The state should raise the bar that makes practitioners access the funds; service vendors and health-care practitioners have increasingly getting access to the funds opening a loophole of some unqualified practitioners to access the funds.

Some policies to make the process tough include having a probationary period to the practitioners, asking for certificate of good conduct and clearance from relevant professional bodies (United States Attorney Southern District of New York, 2011).

Professional bodies

Professional bodies have the mandate of creating sanity, professionalism, and dignity in their members; they have a major stake to play when it comes to the defraud and preventing it.

To ensure that they have principled practitioners who practice professionalism, they should deploy only those people who have proven track record of ethical behavior. On the other hand, the state government should empower the bodies that they only offer an operating certificate to those who have successfully been cleared by the professional body.

Periodically, the bodies should work with the government to audit the program and offer quality and specialized advices to the state government regarding the prices that have been quoted by practitioners. In their capacity as professional bodies, they should have stick method of punishing those people who are not acting ethically or not providing professional services to the communities (Media Center, 2011).

The practitioners

Although the program has been misused by some practitioners, the truth of the matter is that there are people who have been successful in the sector and are willing to offer professional services; such professionals should be used to advice the state and professional bodies on the right billing.

On the other hand, practitioners should understand that the main aim of medical care provision is offering quality services and not defrauding the state. Cost of medication can be reduced if practitioners can perform their duties with professionalism: some costs that can directly be controlled by practitioners on how he/she uses the available resources.

Practitioners should be in the forefront guiding the cost management programs instead of enacting policies to defraud the state; they should devise cost management strategies to the benefit of their department. Managing finances effectively in a hospital is a vital function that requires collaboration of both patient care units and administrative units.

The nursing unit is one costing point of hospitals where they have a budget they want financed, the department should be given an appropriate allocation of hospital finances according to their needs, when the resources have been allocated, they need to be managed professionally and effectively.

Practitioners should oversee the effective management of funds and ensure that all operations are managed in a cost effective way; they need support of other nurses to attain this noble goal. For example when making financing budgets, nurses should be consulted since they have direct interaction with medical staffs and the patients, thus they can offer sound ideas and information for decision-making (Yai Network., 2011).

Practitioners should be occasionally trained on the best working ethics and how to offer professional services, when undergoing the trainings; they should be encouraged to give their observations on how they can improve the services of the problems they are encountering (Lovitky & Ahern, 1999).

The patients or public

Practitioners get a chance to exploit the system when they offer services to patients; the patients are to some extent reluctant to know what goes behind the scenes as they believe that the government will cater for the service they have received. They need to be trained that the right they have been given can be exploited by some unethical practitioners thus they need to monitor them.

Some of the methods that the patients can use are to ensure they know the exact bill that they have been billed by the practitioner and given a copy of the bill, in case there is something that they don’t understand, they should ask for clarification from the practitioner. The practitioner should append their signature on the copy to ensure that the patient can enforce the document against the practitioner incase need be.

Anytime that a practitioner feels that the bill was exaggerated, there should be a direct calling line, most likely a toll free line, that they can enquire form the Medicaid managers. When conducting compliance audits, patients should be called in as witnesses of a fraud case, this should be set as a condition of using the card.

Patients can offer quality information on which facility is expensive and why, such information is important to know the exploiting facilities; from the information offered, then the government can be able to act (Malanga, 2006).

Implementation strategy

To implement the above possible solutions, the government and professional bodies are in the center stage, they should start by enacting policies and laws that criminalize the act and offer harsh penalties to the offenders.

After the volume of legislation and the punishment has been made, then the government should lead a campaign that train practitioners on the law and how it will impact on those people who do not follow them. This can be done through the media, the professional body, in schools among other places.

With the programs, the last focus should be on the public and the role they can play, they should be trained on their rights and the role they have in the entire prevention process. When the practitioners and the people have known the best way, the next important thing is to see the law enforced (Kutz, 2010).

Consideration of success measurement techniques

The measurement parameters that the state should use to ensure that the programs are working on well include:

Continuous assessment of quality of health care services; the services should be seen improving
Reducing of the Medicaid budget bill
Harmonization of costs of similar services
Affordability and accessibility of the medical care service.

The above are the parameters that should be seen improving (Office of Medicaid Inspector General, 2011).

Conclusion

Medicaid Fraud has continued to be a challenge to federal and states government, however with collaboration of all stakeholders, the vice can be solved.

The main stakeholders in the prevention program should be the government (through ministry of health and the office of the Attorney General), professional bodies, the practitioners, and patients. Each of them should be well empowered and willing to play its part to prevent the growth of the vice.

References

Heeley, L., & Whitley, G. (1998). Beyond Compliace. Retrieved from HealthCare Executive.

Lovitky, J. A., & Ahern, J. (1999). Designing compliance programs that foster ethical behavior. Retrieved from Healthcare Financial Management.

Malanga, S. (2006). How to Stop Medicaid Fraud. Web.

Matusicky, F.,& Cheryl, C. (1998). Building an effective corporate compliance program – General Health System – Special Section: Fraud and Abuse. Healthcare Financial Management. Web.

Meulemans, M. (2011). Major Medicaid Uncovered: APS Healthcare Pays13 milliom Settlement. Web.

Kutz, D. (2010). Medicaid: Fraud and Abuse Related to Controlled Substances Identified in Selected States: Congressional Testimony. New York: DIANE Publishing.

Media Center. (2011). Attorney General Schneiderman Announces $18 Million Medicaid Fraud Settlement With State’s Largest Residential Service Provider. Web.

Office of Medicaid Inspector General. (2011). Corporate Integrity Agreement between the NewYork office of Medicaid and YAI. Web.

Scott’s, R. (2011). Daphne Campbell faces Medicaid-fraud investigation. Web.

United States Attorney Southern District of New York. (2011). Manhattan U.S. Attorney Announces $18 Million Civil Fraud Settlement with New York’s Largest Operator of Facilities for Adults with Developmental Disabilities. Web.

Yai Network. (2011). Serving People with Disabilities and their Families. Web.

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