How to Avoid Medicare –Related Fraud & Abuse Essay

The critical regulatory issue in health care selected for this assignment is regulation of Medicare claims. Medicare is a well-known federal health insurance program aimed at providing certain benefits to the elderly and to the disabled groups of the US population (Elder Consumer Rights, 2017). The health care organizations have to bill the provided health care services to Medicare. In fact, Medicare fraud and abuse claims are common types of current legal issues in the United States health care. One of recent legal cases is the case of USA v. Juan Oleo, No. 11-1360 (6th Cir. 2012). The identified issue went to the court to have the court determine the outcome of the case. The United States of America is the Plaintiff – Appellee in this case, while Juan De Oleo is the Defendant – Appellant. The facts of the case are the following: Juan De Oleo and his colleagues were involved in a beneficial form of Medicare fraud.  They established phony medical clinics in order to earn money. They rented an office, furnished it effectively and provided the proper medical equipment to deliver health care services to patients. Besides, they hired a physician who agreed to be engaged in the fraud. After these arrangements, “they bribed Medicare beneficiaries to travel to the fraudulent clinic and submit their insurance information without receiving treatment” (USA v. Juan Oleo, No. 11-1360 (6th Cir. 2012). De Oleo and his colleagues wanted to create a profitable business scheme when they acted as conspirators, utilizing the obtained insurance information of their clients to bill Medicare for expensive medications. In fact, the court gave permission to the government to effectively use the facts that showed De Oleo’s intent and prior knowledge of how to commit Medicare fraud at the clinic. There was much evidence that other fraudulent clinics were established in the states like Florida and Michigan. De Oleo was one of the participants of the creation of the identified clinics. All in all, there was much evidence to support the Defendant’s conviction of creation the fraudulent clinics. Hence, the U.S. Court of Appeals for the Sixth Circuit affirmed De Oleo’s conviction and type of sentence.

In general, the identified regulatory issue has a significant impact on the health care industry. It has been found that the elderly consumers are the key targets of scammers who want to earn money using this vulnerable group of the US population. There are several federal consumer protection agencies, including the Federal Trade Commission (FTC) and the Consumer Financial Protection Bureau (CFPB), which help to solve the problems faced by the elderly people (Elder Consumer Rights, 2017). Medicare fraud affects the overall functioning of the health care system. According to experts, “A form of elder abuse involves billing a senior’s health insurance provider, or Medicare, for services the senior is not actually receiving” (Elder Consumer Rights, 2017). It becomes clear that Medicare fraud has a negative impact on the quality of care, as well as the elderly patient’s health. It is necessary to understand that Medicare fraud is easy to implement without the proper regulation system (Sparrow, 2008).

As a matter of fact, there are several the regulations and laws pertaining to the selected issue from a state level and a federal level. Federal laws governing Medicare fraud and abuse are False Claims Act (FCA), Anti-Kickback Statute (AKS), Physician Self-Referral Law (Stark Law) , Social Security Act  and United States Criminal Code (Medicare Fraud & Abuse: Prevention, Detection, and Reporting, 2016). These regulations and laws are focused on specifying the types of remedies imposed by the government on the people and organizations that commit fraud in the Medicare Program. Besides, State Medicare agencies ensure regulation of the issues related to Medicare program. The Medicare and Medicaid Patient and Program Protection Act of 1987 is one of the key laws applied to resolve various legal issues. Medicare and Medicaid Patient Protection Act of 1987, as amended, 42 U.S.C. §1320a-7b (the “Antikickback Statute”) ensures criminal penalties for the illegal acts that affect Medicare services and state health care reimbursable services. State laws and regulations that regulate health plans are used to support the functioning of Medicare program (Sparrow, 2008).

Conclusion

Thus, it is necessary to conclude that the current legal case, namely USA v. Juan Oleo, No. 11-1360 (6th Cir. 2012), helps to have a good understanding of the significant role of regulation of the Medicare program to avoid Medicare –related fraud and abuse. There is a need for promoting integrity of Medicare services through the use of the proper strategies like provision of audits, regular policy reviews, and identification and monitoring of the key vulnerabilities of the federal health insurance program. For example, the Center for Program Integrity (CPI) allows strengthening the program’s integrity through detection and control of Medicare fraud and abuse cases. It is necessary to help patients resolve their problems, as well as force health care providers to make informed decisions regarding their contractual interactions with the Medicare program. Medicare fraud and abuse claims are caused by improper regulation of the program implementation and illegal actions like billing for health care services that are not covered by the Medicare program, the products (e.g. medications) and health care services that not actually provided by health care providers , and improper coding practices. As most Medicare claims are relied on the use of the federal False Claims Act, the acts of fraud and abuse should be addressed promptly by relevant regulatory agencies.

References

 Elder Consumer Rights. Justia US Law.Retrieved from:<https://www.justia.com/consumer/elder-consumer-rights/>

Medicare Fraud & Abuse:Prevention, Detection, and Reporting.(2016).Department of Health and Human Services Centers for Medicare & Medicaid Services.Retrieved from:<https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/fraud_and_abuse.pdf>

Sparrow, M. K.(2008).“Fraud in the U.S. Health-Care System: Exposing the Vulnerabilities of Automated Payments Systems,”Social Research,75(4):1151-1180.

USA v. Juan Oleo,No.11-1360(6th Cir. 2012).Justia US Law.Retrieved from:<http://law.justia.com/cases/federal/appellate-courts/ca6/11-1360/11-1360-2012-09-20.html>

The terms offer and acceptance. (2016, May 17). Retrieved from

[Accessed: March 29, 2024]

"The terms offer and acceptance." freeessays.club, 17 May 2016.

[Accessed: March 29, 2024]

freeessays.club (2016) The terms offer and acceptance [Online].
Available at:

[Accessed: March 29, 2024]

"The terms offer and acceptance." freeessays.club, 17 May 2016

[Accessed: March 29, 2024]

"The terms offer and acceptance." freeessays.club, 17 May 2016

[Accessed: March 29, 2024]

"The terms offer and acceptance." freeessays.club, 17 May 2016

[Accessed: March 29, 2024]

"The terms offer and acceptance." freeessays.club, 17 May 2016

[Accessed: March 29, 2024]
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