President George Bush proposed a two part strategy with initial implemented drug coverage to low-income beneficiaries coupled with a White House task force to develop a plan to reform Medicare (Health Policy, 2001). Under this plan beneficiaries with income 135% below the national poverty guidelines would be eligible for full prescription drug coverage and a sliding scale would be provided for those under 175% (Health Policy 2001).
The most controversial aspect of these proposals was whether or not Medicare should remain a public insurance that is managed by the federal government. Supporters felt that this program should continue existing programs in scope and nature while opponents claim that a program of this sort should exist in the private market. Proposals suggested that a national standard for drug benefits should be established with all beneficiaries being eligible for standard benefits and increased benefits being given to those who incur catastrophic expenses.…...

Medicaid and Medicare Fraud
Describe health news story combating health care fraud Medicare Medicaid• Examine evaluate corporate structure governance, culture, focus social responsibility • ecommends

Medicare and Medicaid fraud: An overview

Medicare and Medicaid fraud: An overview

While there is still little consensus regarding the best ways to go about enacting healthcare reform, one issue that unites both Democrats and epublicans is the need to eliminate Medicaid and Medicare waste, fraud and abuse. According to a 2009 CBS News report: "One tiny pharmacy in a Hialeah [Florida] strip mall went from billing Medicare $13,000 in May to billing nearly a million dollars a month later," and regulators took no notice (osen & Bach 2009:1). It has been estimated by the Federal Bureau of Investigation (FBI) the fraudulent billings to public and private health care programs are 3 -- 10% of total health spending, $75 -- $250 billion per year on average, and that is…...

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References

Iglehart, John K. (2010, July 22). The ACA's new weapons against health care fraud

New England Journal of Medicine, 363:304-30

Morris, Lewis. (2008, September). Combating fraud in healthcare: An essential component of any cost containment strategy. Health Affairs, 28 (5): 1351-1356.

Taitsman, Julie K. (2011, January 11). Educating physicians to prevent fraud, waste, and abuse.

Fraudulent activities such as these resulted in violations under the act, including a fine of not more than $25,000.00 or imprisonment for not more than five years, or both.
Analysis of Current Fraud legal analysis of the current fraud committed in the Medicare and Medicaid programs indicates that reforms are in place to detect this fraud, and the involvement of governmental, local and federal police and investigation authorities has increased as well. For example, the National Center Policy for Analysis (2001) reports that 350 FI agents are now investigating a record 2,300 potentially fraudulent cases in the medical industry. In addition, various government antifraud units are being allowed to tap into the Medicare trust fund for the first time to fund their budgets; $104 million for 2001 and more than $200 million for 2002. As a result of the high volume of Medicare and Medicaid fraud, in the past few…...

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Bibliography

Bennett, M. (2007). Criminal Prosecutions for Medicare and Medicaid Fraud. Retrieved April 4, 2007, at  http://www.aapsonline.org/fraud/fraud.htm .

Antos, Joseph. (1997). The Magnitude of the Financial Crisis in Medicare. 1997

Subcommittee on Health Care, United States Senate.

National Center for Policy Analysis (2001). Fraud in Medicare. Retrieved April 4, 2007, at  http://www.ncpa.org/health/pdh5.html .

Medicare and Medicaid Services (CMS), previously the Health Care Financing Administration (HCFA), that by the time 2011, health care expenditure will arrive at $2.8 trillion, as well as it will bill for 17% of the Gross Domestic Product. As a result, it is no revelation that white-collar offenders observe health care deception as a rewarding effort. Certainly, the General Accounting Office ("GAO") quotes that such deception accounts for up to 10% of entire health care expense (3).
As health care deception outlays taxpayers almost $100 billion a year, federal, as well as state agencies have given health care fraud tribunal a key center of attention. All through her term, Attorney General Janet Reno made impeaching health care fraud a top precedence at the Department of Justice ("DOJ"), subsequent only to brutal offenses (3).

The government focuses its pains to perceive, as well as take legal action against health care fraud in…...

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Bibliography

(1) Adelaide Few & Jay Trezevant, Fighting the Battle Against Health Care Fraud & Federal Enforcement Actions, 72 FLA. B.J. 34, 34-6 (1998)

(2) Alice A. Love, Leniency Offered Health Care Providers that Admit Federal Fraud, S.D. Union Trib., Oct. 22, 1998

(3) Andy Bunds, The results of the Health Insurance Regulations on Health Care Fraud and Abuse, 72 Mont L. Rev. 63, 72 (2001)

(4) Brian A. Kaset, Sailing Without Safe Harbors: Physician Recruitment and the Law of Fraud and Abuse, 9 Healths Span. 9, 9 (1992)

Fraud and Abuse
United States v. Greber -- 3rd Circuit, 1985

Facts:

Dr. Greber's company, Cardio-Med, supplied Holter monitors, a device worn by patients that records heartbeats for later interpretation. Investigations showed that Cardio-Med billed Medicare and gave a portion of each payment to the prescribing physician, under the heading, "interpretation fees," even when Dr. Greber actually did the interpretation of the data. It was found that the fixed percentage paid to the referring physicians was more than Medicare allowed for such services. Further, Medicare requires that the device be used eight hours or more to qualify for payment. Cardio-Med and Dr. Greber reported longer operation times than the patients actually used their monitors.

In 1977, Congress changed the fraud statute of Medicare to clarify such problems as "kickbacks." In the revised statute, kickbacks were defined as any remuneration that might in any way be perceived as encouraging one company to do business with…...

Healthcare Law -- Ethics & Policy
Memo to ABC Hospital Board of Directors: How to develop strategies to help mitigate abuse and fraud within our organization by understanding fraud and abuse issues.

The Department of Health and Human Services has provided a great deal of good information for healthcare professionals and the public in terms of ways to avoid and/or deal with fraud and abuse. This document reflects the ways in which this hospital can be on the lookout for fraud and abuse when it comes to Medicare. This document will also explain the difference between fraud and abuse in the Medicare system.

Medicare Fraud

Typically Medicare fraud means a person in this hospital -- or a doctor affiliated with this hospital contractually -- would knowingly submit false statements or somehow misrepresent what his or her services actually were, in an attempt to cheat the federal government. Also a healthcare person could solicit, pay…...

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Works Cited

Department of Health and Human Services / Centers for Medicare & Medicaid Services.

Medicare Fraud & Abuse. Retrieved March 1, 2015, from  http://www.cms.gov .

American Hospital Association (AHA) might be interested in the pending legislation:
Although all three positions of the proposed bill would be of concern, two of the three would cause serious ramifications for the AHA and its members. The first would be the 5% annual reduction. This cut equates to a very serious amount of income for the industry especially if the cut was scheduled for across the board reductions. Hospitals and nursing homes are already working at bare bones and more cuts would cause serious financial dilemmas if implemented. If the cuts are unique to certain aspects of the Medicare billing system, the AHA would need clear details of where the proposed cuts would actually be coming from.

The second of the three major concerns would be the simplification for assessing penalties to providers accused of abusing the Medicare payment system. It is the AHA's stance that providers should still be…...

Miscoding on the Billing Forms Discussion Board
The fundamental basis for auditing Medicare and Medicaid billing is that the services provided are confidential, patient privacy must be protected, and the written word of the provider is the record of service provision upon which a review must be initiated (Harris, 2007). Auditing, however, must extend beyond the written record to establish that the services were actually provided to the patient or client and that the services were rendered according to the conditions described in the provider's written record (Harris, 2007)

As the practice manager, I would remind the physician that every employee has a duty to cooperate and a duty of loyalty to the employer. And I would explain that these duties obligate employees to comply with reasonable directions from their employers during an internal investigation. The employee should be party to a conversation that an internal investigation may or may not commence…...

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References 2

Harris, D. (2007). Contemporary issues in healthcare law and ethics (3rd ed.). Chicago: AUPHA/HAP

Murphy, A.P. And Vandenberg, Q.H. (2003). How to conduct a fraud investigation. Retrieved from  http://www.mhtl.com/pdf/How%20To%20Conduct%20A%20Fraud%20Investigation.pdf 

U.S. Department of Health and Human Services and U.S. Department of Justice. Stop Medicare fraud. Retrieved from http://www.stopmedicarefraud.gov/aboutfraud/index.html

UP FOR DISCUSSION NOW: Can you think of a reason why Dr. Jones might over rule his wife (Yikes!!) if she tells him not to buy the machine (which is the conclusion of the sample solution, and what 1/4 of you determined in your own papers)? What might be some of the benefits of having the machine, even with it losing money? (Think about all the DaVinci robots being bought now by competing hospitals...)

Amerigroup Illinois Inc. Fraud CaseAmerigroup Illinois Inc. was found guilty in 2006 under the Federal Claims Act and the Illinois Protection Act. Amerigroup and its subsidiaries denied enrolling pregnant women and unhealthy patients in its managed care program in Illinois. Amerigroup received payment from the state and federal governments to operate a Medicaid health care program for low-income earners (Department Justice, 2008). Amerigroup was mandated by law to enroll all applicants eligible for the care under the Medicaid program. The State of Illinois and the Federal government of the US filled claims against Amerigroup, alleging that the corporation overlooked their responsibility of enrolling unhealthy parents and pregnant women since it would have been more expensive and lowered the profit margins earned by the patients.The court entered into a $334 million judgment against Amerigroup under the Federal Claims Act and the Illinois Whistleblower eward and Protection Act. The Jury found the…...

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ReferencesDepartment Justice. (2008). #08-723: Amerigroup Settles Federal & State Medicaid Fraud Claims for $225 Million (2008-08-14). Justice.gov. Retrieved 12 July 2021, from   of Justice. (2021). Justice Department Recovers Over $2.2 Billion from False Claims Act Cases in Fiscal Year 2020. Justice.gov. Retrieved 12 July 2021, from  https://www.justice.gov/opa/pr/justice-department-recovers-over-22-billion-false-claims-act-cases-fiscal-year-2020 .Rudman, W. (2009). Healthcare Fraud and Abuse. Online Research Journal, 6. Retrieved 12 July 2021, from  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2804462/ .The False Claims Act. Justice.gov. (2021). Retrieved 12 July 2021, from  https://www.justice.gov/civil/false-claims-act .USSC Guidelines. Guidelines.ussc.gov. (2021). Retrieved 12 July 2021, from  https://guidelines.ussc.gov/gl/%C2%A78B2.1 .https://www.justice.gov/archive/opa/pr/2008/August/08-civ-723.html .Department

The facts that you have provided indicate extremely troubling circumstances that could seriously jeopardize the welfare of your organization. It is well-settled law that entities contracting for the services of subsidiaries are legally responsible for legal and ethical improprieties committed by those subsidiaries irrespective of whether or not the contracting organization had any specific involvement in or knowledge of those actions. Accordingly, we would strongly advise that you take immediate action to rectify the situations described in the manner outlined in our recommendations below.

ecommendations

To avoid the potentially serious criminal, civil, and financial consequences arising under MWHC's respondeat superior responsibility to prevent fraud and abuse in connection with its association with subsidiaries, it is hereby recommended that MWHC immediately:

1. Instruct the subsidiary to cease and desist from offering its contracted home health agency employees compensation of any kind in connection with client durable medical equipment (DME) orders from the subsidiary.

2. Instruct…...

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References

Reid, T. (2009). The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care. New York: Penguin Group.

USDHHS. (2004). U.S. Department of Health and Human Services-Office of Inspector

General-Statement of Organization, Functions -- and Delegations of Authority.

Federal Register. Vol. 69, No. 127; July 2, 2004. Retrieved November 14, 2010,

In the case of pill mills, participating physicians and pharmacists bill insurance companies or Medicare for prescription drugs, allowing participating beneficiaries to resell those drugs to criminal middlemen. The pharmacy then repurchases the drugs at a lower cost. According to the USGAO, any misuse of beneficiary identification information is a felony.
Criminals may also steal beneficiary information by creating drop boxes. The drop box scheme involves establishing a phony health care company in order to obtain insurance or Medicare payments. Like the drop box scheme, the pill mill scheme, and the rent-a-patient scheme, third-party billing also involves felony acts. Illegally obtaining beneficiary identification numbers, a criminal can use third-party billing agents to receive insurance payouts. The third-party billing company may not even be aware of the scheme. In other cases, the third-party billing company is a part of the scheme, defrauding by tacking on fraudulent claims to legitimate ones and…...

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References

Cornell University Law School. "Health Care Fraud." Retrieved Aug 7, 2008 from  http://topics.law.cornell.edu/wex/healthcare_fraud 

United States General Accounting Office (USGAO). "Health Care Fraud." Retrieved Aug 7, 2008 from http://209.85.215.104/search?q=cache:NcKXTYWPgDEJ:www.gao.gov/new.items/os00015t.pdf+health+care+fraud&hl=en&ct=clnk&cd=5&gl=us&client=firefox-a

Corporate fraud as a dishonest activity for organizations that is considered as white collar crime has serious legal implications. Though it can be difficult to detect and catch, it is important to prevent it by creating effective and efficient policies for the organizations that ensure an efficient system of checks and balances exists in the organization for its physical and fiscal security. Whenever fraud happens in a company or organization, it often takes the form of hiding sources of revenue, overstating expenses or growth, or disguising payments made to individuals in the company. Often, fraudulent activities within the organization are complex in nature and have a gross impact on the financial nature of the organization. It is usually perpetrated by the company management and other employees are often unaware of these fraudulent activities (Mele, 2005).
Corporate fraud, as difficult as it is to prevent, often has a ripple effect whereby when…...

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References

Bertrand, V. (2009). Organizational Isomorphism and Corruption: An Empirical Research in Russia. Journal of Business Ethics, 89(1), 59-76.

Federal Bureau of Investigation. (2014). Rooting out health care fraud is central to the well-being of both our citizens and the overall economy. Retrieved April, 2014, from  http://www.fbi.gov/about-us/investigate/white_collar/health-care-fraud 

Mele, D. (2005). Ethical Education in Accounting: Integrating Rules, Values and Virtues. Journal of Business Ethics, 57(1), 97-109.

Panda, J.K. (2006). Accounting & Finance For Management. New Delhi: Sarup Book Publishers Pvt. Limited.

The Act creates a positive balance between government interests to save money and the interests of Medicare recipients to receive a wide range of drugs for their specific needs. The current ban on government negotiations with pharmaceutical companies serves to protect Medicate recipients by using the positives of the free market, such as the experience and purchasing power of PBMs. hile there are serious potential problems with this approach, such as the potential for fraud between pharmaceutical companies and private interests, overall the ban on government negotiations with pharmaceutical companies provides a good balance between recipient and government interests.
orks Cited

American Legislative Exchange Council. Prescription Drugs. 19 October 2005. http://www.alec.org/2/4/talking-points/7.html

Barry, Patricia. New Salvos in the Prescription Drug ars: Class action suits are exposing schemes that gouge consumers. AARP Bulletin, January 2005.

19 October 2005. http://www.aarp.org/bulletin/prescription/a2005-01-06-salvos.html

Dealey, Sam. Drug Dealings: Democrats had it right before. National Review Online, May 05, 2004, 9:12 A.M.…...

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Works Cited

American Legislative Exchange Council. Prescription Drugs. 19 October 2005.  http://www.alec.org/2/4/talking-points/7.html 

Barry, Patricia. New Salvos in the Prescription Drug Wars: Class action suits are exposing schemes that gouge consumers. AARP Bulletin, January 2005.

19 October 2005.  http://www.aarp.org/bulletin/prescription/a2005-01-06-salvos.html 

Dealey, Sam. Drug Dealings: Democrats had it right before. National Review Online, May 05, 2004, 9:12 A.M. 19 October 2005.  http://www.nationalreview.com/comment/dealey200405050912.asp

healthcare issues country. How solve ongoing problem Medicare Fraud Abuse government sufficient effective regulation enforce. If, resolve problem? recommendation ? It Economics Healthcare economically sound.
Economics of healthcare

The population of the modern day society is faced with incremental pressures, but also incremental challenges, and these new issues impact all aspects of life, including the provision of healthcare services. For instance, the more and more technological developments made within the medical and pharmaceutical industries improve the quality of the medical services and as such the life expectancy of the patients. Then, the sustained academic research conducted also improves the quality of the services and the overall quality of the medical act.

In spite of the developments made, it must also be noted that the provision of healthcare services in the United States is a complex situation, with numerous ramifications and challenges. On a first note, it is revealed that the population of…...

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References:

Angell, M.,2002, The forgotten domestic crisis, The New York Times,   last accessed on August 8, 2011http://www.nytimes.com/2002/10/13/opinion/the-forgotten-domestic-crisis.html 

Cunningham, W., 2003, The development of the U.S. health care system and its problems, UCLA Schools of Medicine / Public Health, last accessed on August 8, 2011http://www.ph.ucla.edu/hs/hs_100_4_02_lecture_cunningham.pdf

Garson, A., 2000, The U.S. healthcare system 2010, Current Perspectives,   last accessed on August 8, 2011http://circ.ahajournals.org/content/101/16/2015.full 

Gratzer, D., Why isn't government healthcare the answer? Free Market Cure,   last accessed on August 8, 2011http://freemarketcure.com/whynotgovhc.php 

Accounting and Audit Enforcement 1. The Sarbanes-Oxley Act applies to publicly-traded companies. Thus, it does not apply to non-profit entities. Nor does it apply to for-profit entities that are not publicly-traded. This is because SOX was passed specifically to address instances of accounting fraud in publicly traded companies that were undermining consumer trust in the capital markets (101.com, 2018). A publicly traded companies has a variety of different obligations under SOX that will help to reduce the opportunities and incentives for accounting fraud. Both opportunity and incentive are components of the fraud triangle – one needs to have a perceived need to commit the fraud and the circumstances with which to do so (ACFE, 2018).
Non-profit organizations have no obligations under SOX. However, there is a school of thought that holds that non-profit entities can benefit from some of the recommendations and mandates that SOX contains. Fritz (2016) writes that "non-profits are…...