Medicare And Fraudulent Transactions Essay

773 words - 4 pages

Due to the sheer volume of billing received each month, it is impossible for the system to review all the information before payment has been released to providers. This has led to a reactive approach in dealing with fraudulent transactions. Medicare database systems are not discovering fraud until after the fact and thus recovering funds can be challenging. As a result, over the last two decades, several legislations have been enacted to assist the Office of Inspector General (OIG) to investigate and prosecute offenders that have committed fraudulent billings against the taxpayer funded insurance system. The False Claim Act has been successful in prosecuting, collecting monetary sanctions ...view middle of the document...

As Blank, Kasprisin and White (2009) for each criminal count the defendant was convicted of are considered a separate offense and carry its own sentence. The FCA statue obtained over three billion dollars in recovery in the year 2011 alone. Lastly as part of the FCA, the OIG is required to exclude providers from the taxpayer funded Medicare/Medicaid insurance programs if determined criminal fraud as occurred.

The Recovery Audit Contractor (RAC) is five companies that are compensated to locate waste, fraud and abuse within the Medicare/Medicaid system. The RAC’s work in specified areas of the country and analysis claims submitted for over/underpayment to providers (Gingerich, 2009). Once inaccuracies are traced RAC’s adjusts the underpayments; combined with submitting payment requests from providers if necessary for overpayments. Another key element of the RAC program is the review of medical equipment and supplies. The RAC’s examine closely the claims for these types of supplies for irregularities such as higher claims in one particular area or by one specific supplier. The RAC’s review medical records in conjunction with supplies requested to determine if medically necessary within policy requirements. This particular programs has been effective in locate both underpayments and overpayments between 2005 and 2008 netting a savings of approximately 800 million (Gingerich, 2009).

Many providers especially new to the system could have a difficult time completing the claim forms...

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