Medicaid: A Health Care State Administered Program

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Table of Contents

Introduction
False claims act
Comprehensive Medicaid Integrity plan
The Deficit Reduction Act (DRA)
Conclusion
Reference List

Introduction

Medicaid is a health care state administered program that is available to legible low-income individuals and families who are recognized by the state and federal law. The program does not send money directly to beneficiaries, but to individuals chosen health care providers. This program is comprehensive and complex and a target for fraud either knowingly or ignorantly by those involved. This is the reason why measures have been put in place to protect the government against such acts. These measures are discussed below and how they protect the program against intentional and reckless fraud by individuals or entities (Welch, 2006).

False claims act

This is also referred to as the ”Lincoln Law” in the US federal law, and provides the citizens and tax payers of the US a legal framework to protect the government against fraud by either individuals or entities. This provides that a person who has knowledge, either directly or indirectly, of an act meant to fraud the government, to file a law suite against the defrauder. An act of fraud happens when a person deliberately or ignorantly uses misrepresentation or dishonest ways to get something one is not entitled to.

The fraud can occur if the person or entity falsify information or deliberately ignores information or carelessly represents inaccurate or false information in order to receive payment or benefits from the government. In this Act also a person who provides false information, which is then submitted to the government by another, violates this act and is liable for prosecution. This Act protects the government against sophisticated fraud by ensuring the money used on various programs such as Medicaid is actually used for the health and welfare of the beneficiaries (Welch, 2006).

This has been made effective by creating a partnership between law enforcers and taxpayers. This reduces cost in Medicaid by ensuring that health care providers do not file claims on false grounds in order to benefit unfairly. Such people can be prosecuted and the money reclaimed by the state.

Comprehensive Medicaid Integrity plan

This is a five-year plan developed and implemented by the Centers for Medicare and Medicaid Services (CMS), and other partners under the Medicaid Integrity Program put in place by the Deficit Reduction Act (DRA) of 2005. This program is meant to combat health provider fraud, waste and abuse of the dollars used for provision of health care and welfare of its recipients. The plan outlines in detail the use of contractors to assess provider activities, audit recipient claims, identify over payments and create awareness to the providers. It also mandates CMS to provide technical assistance, guidance and support in combating fraud to states (Taylor, 2006). Through this plan the defrauders can be able to be tracked down even if they cross state lines and be prosecuted for liability in the False Claims Act.

The Deficit Reduction Act (DRA)

This is legislation enacted in February 2006 to protect government domestic entitlement programs against misuse and fraud, such as Medicaid and Medicare. This Act added to the resources of CMS in fighting and combating fraud, waste and abuse of the Medicaid program. The Act put in place the Medicaid Integrity Program in section 1936 of the Social Security Act, an approach to avoid and minimize provider fraud, waste and abuse in the Medicaid program. Under the Act also, the CMS is to develop a five-year plan, the Comprehensive Medicaid Integrity Plan (CMIP) as covered above (Zimmerman, 2000). Through this Act the CMS gains legal framework to investigate and audit claims by both providers and beneficiaries to avoid unfair benefits.

Conclusion

The government has been successful to a certain degree in controlling the costs of these programs by avoiding unfair benefits. What remains to be done is to empower these institutions to perfume effectively, and the public to be able to take action to suspected fraudsters.

Reference List

Taylor, M. (2006). Outlier Probe May Widen. Modern Healthcare 36 (27); pg. 8-10. Web.

Welch, J. M. (2006). Mission Impossible: Stopping Medicaid Fraud. Journal of Health Care Compliance 8 (5); pg. 57, 2 pgs. Web.

Zimmerman, A. (2000). Wal-Mart Sues Arkansas to Stop State On 2-Tier Medicaid Reimbursements. Wall Street Journal, (Eastern edition). pg. 1. Web.

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Medicaid: A Health Care State Administered Program

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