The Medicaid Integrity Program - Essay Example

Medicaid The Federal False Claims Act (31 USC 3729-33) makes it illegal for any organization or person to consciously make a false record or file a false claim for payment to the government. It allows citizens to bring actions against federal contractors for false claims; they receive a percentage of the recovered damages. The filing is done by people with insider information who are known as whistleblowers. The original False Claims Act was passed on March 2, 1863, during the Civil War. It basically provided a way for seven conditions to monitor the activities of trade with the federal government.

These seven conditions didn’t apply to senior executive branch officials, members of Congress, members of the armed forces, or members of the judiciary. The complaint had to be sealed, served on the Government, not on the defendant, and be accompanied by a list of proof for the claim. However, amendments in 1986 significantly sharpened the focus to include protection for employees who filed claims, more compensation for whistleblowers, and more liability for those who were a part of the fraud process.

There were even tighter restrictions added in 2009. Through this method, the government has been able to reclaim more than $22 billion from 1987 through 2008. There have been significant recoveries of tax money through the FCA with regards to selling unlicensed pharmaceuticals to Medicaid by big pharma companies. The burden for monitoring this rests with the individual states. In 2007, section 1909b of the Social Security Act requires the OIG (Office of Inspector General) to work with the Attorney General of the U.S. to meet certain requirements in an effort to eradicate Medicaid fraud; that State’s percentage of the Social Security funding depends on reporting and facilitating the location of fraud. (OIG, nd) The Federal Deficit Reduction Act of 2005 amended the Social Security Act to include a mandate for all states transacting more than $5 million in Medicaid funding to comply with certain new requirements mandating policies and procedures for employee education with regards to false claims, abuse, and fraud, as well as those to protect whistleblowers.

(Sheehan, 2007) The Medicaid Integrity Program was established in section 6034 of the Deficit Reduction Act of 2005 under the Social Security Act in section 1936. This plan appointed the Secretary of Health and Human Services to devise a comprehensive 5-year plan designed to rid the Medicaid system of abuse, fraud, and waste. The first plan was released in July 2006, covering 2006-2010; a second plan was released in October 2007, covering changes from 2007-2011. The Medicaid Integrity Group focused on the issues of communication between systems and collaboration, program planning and management, information research and management, State program integrity operations, and Medicaid Integrity contracting, as well as ensuring accountability.

(Centers for Medicaid and Medicare Services, 2008) While at the surface level it appears that huge amounts of money were returned through whistle-blowing activities; in reality, it caused the providers and their insurance personnel to become much more innovative and creative with labeling procedures and coding so as to get the maximum amount from each procedure. This creates frustration for patients who need to return to providers’ offices more often in order to receive comprehensive care. Each visit is coded and billed separately so as not to appear fraudulent.

Primary Care providers only receive $6 per month for each person on their caseload rosters. Therefore, the best physicians don’t take on Medicaid patients as they require a lot of care, tend to be a subculture that participates in risky behaviors, and require multiple office visits to meet their needs. We spend the most per capita on health care in the U.S.; although there has been progress, there is still a critical need for a much better and more efficient quality-driven system.