Thesis

Combating Medicare Fraud and Abuse

In the United States, health care fraud is a serious problem and a growing concern in the health care community, especially in the Medicare program. Many Medicare seniors have fallen prey to the various scams that exist, which creates a major threat to the Medicare Trust Fund. Acts and laws have been created to combat this problem. Medicare anti-fraud and abuse partnerships and agencies have been established to assist with combating fraud and abuse. The Centers for Medicare and Medicaid Services (CMS) also partners with contractors to help investigate fraud and abuse. Various hotlines and websites have been created and provided to Medicare beneficiaries to report fraud and abuse. Despite having all of this in place, combating this problem remains a challenge. This study aimed to provide an overview of the reasons for Medicare fraud and abuse and the policies that exist to combat it as well as recommendations on how to prevent health care fraud and abuse in the future. Findings show that although there are policies and laws in place, fraud and abuse exist due to it being difficult to assess. A critical factor is the shortage of available and current fraud records. This is usually obtained by audits that are performed by subject matter experts. Because the providers are presumed to be honest, claims processing systems are not equipped to detect fraud and abuse. Another factor is that there is no accurate way to measure the impacts of fraud because of its deceptive nature. The oversight of the Medicare Administrative Contractors (MACs) verifying a provider's information before providing them a provider identification number risks the integrity of the Medicare program and makes the health care program vulnerable. Due to the lack of oversight, the government must come up with an efficient way to detect and stop fraud and abuse and must react quickly with investigations, prosecutions, and remedies. The claims processing system must be improved to detect fraudulent claims. Once identified, steps must be taken to verify the services before payment is made. The government must get rid of the "pay and chase" model. Applications for potential providers must be thoroughly reviewed before issuing provider numbers. Medicare providers and beneficiaries should be trained in fraud and abuse. Without a drastic change, fraud and abuse will continue.

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