Healthcare Fraud in the US - Essay Example

There are several Statutes, agencies, organizations and partnerships that fight to uphold Medicare integrity by preventing and detecting healthcare fraud. Examples of federal laws governing health care fraud include; Anti-Kickback Statute, Social Security Act, False Claims Act, United States Criminal Code, and  Physician Self-Referral Law (Corr, 2010). The Patient Protection Affordable Act (PPACA) which was formulated in 2010 helps resolve the problem of increased healthcare costs by reducing fraud and abuse. The above action has been adopted by many organizations as the guiding principle in the fight against fraud. The Fraud Enforcement and Recovery Act (FERA) implemented in 2009 helps direct government resources that help in law enforcement efforts of fraud prevention. Some of the organizations geared toward the control of healthcare fraud include the National Healthcare Anti-Fraud Association (NHCAA) which controls Insurance related fraud cases in healthcare. The Public-Private Healthcare Fraud Prevention Partnership among public and private sectors whose sole purpose is to detect and prevent fraudulent payments and claims. Another Federal agency is the Center for Medicare and Medicaid Services (CMS) that conducts policy reviews, and audits, and monitors program vulnerabilities to promote the integrity of Healthcare (Busch, 2008).

In the recent past, the United States has achieved great success in the fight against healthcare fraud through the partnership between the Department of Health and Human Services (HSS) and the Department of Justice (DOJ). The above two organizations have been in charge of the Health Care Fraud and Abuse Control Program (HCFAC). This program has been instrumental in implementing fraud control prevention, detection and reporting systems (Corr, 2010). In 2009, the DOJ and HSS formed the Health Care Fraud Prevention and Enforcement Action Team (HEAT). Under the supervision of the Department of Inspector General, HEAT has been very successful in increasing training on Medicare fraud, improving data sharing with the government and CMS, monitoring and investigating fraud cases, and researching new technology to aid in fraud detection (Corr, 2010). The HEAT has also been instrumental in ensuring defendants are convicted, and millions of fraudulent billings are detected and prevented.

Through the HCFAC program, the DOJ and HHS departments monitor the deposits made to the Medical Trust funds and produce a report detailing the source of the funds and how the funds are appropriated (Sparrow, 1998). The HHS uses a state-of-the-art Fraud Prevention System (FPS) predictive analytic technology to run nationwide predictive algorithms on all Medicare fee-for-service claims. The above algorithm calculates error rates hence allowing fraud detection. Through this program, HSS can reduce improper payments in healthcare by ensuring that all medical care providers submit proper and comprehensive documents (Corr, 2010) The DOJ prosecutes those responsible for healthcare fraud violations.

Some of the common healthcare frauds detected by the HHS and DOJ include; knowingly providing false claims or misrepresenting facts to obtain federal payments that one is not entitled to or knowingly accepting payment for services already reimbursed by the federal Healthcare programs. HEAT also detects when medical practitioners knowingly bill patients for services not rendered, billing for missed appointments or falsifying records to show delivery of supplies not given or billings for missed appointments.  Another common type of fraud detected by the HEAT is the incorrect reporting of diagnoses and procedures by medical practitioners after which they bill for services at a higher level of complexity than the service rendered.

Fraud control in healthcare continues to face numerous challenges such as; Lack of effective detection systems; contact needs to improve detection systems since fraud control is dynamic rather than static, bureaucratic policies on enforcement approaches and lack of resources needed for fraud prevention and detection. By adhering to affordable care, HEAT has successfully addressed the above challenges. This law has ensured the provision of new resources by providing additional funds geared towards healthcare anti-fraud efforts. HEAT also partners with the government and other organizations to help source for grants. The HSS also conduct investigations and research to help develop new and state-of-the-art technologies that can be used in fraud detection. The DOJ and HSS have also overseen the implementation of new laws and sentences used as the guidelines for healthcare fraud. These laws have slowly replaced the traditional bureaucratic policies thus providing speedy and more efficient systems for trying healthcare fraud cases. Through campaigns that help educate the public on how to detect, report, and protect themselves against healthcare fraud incidences, this organization might achieve its goal of eradicating healthcare fraud.