Fraud Case Study Report
Medicare fraud can cost taxpayers billions of dollars and places the health and welfare of Medicare beneficiaries at risk (CMS, 2017). Both over-coding and under-coding constitute Medicare fraud (Dillon & Hoyson, 2014). Knowingly billing for services at a level of complexity higher than services provided or documented in the file creates Medicare fraud (CMS, 2017).
Knowingly submitting, or causing to be submitted, false claims or making misrepresentations of fact to obtain a federal healthcare payment for which no entitlement would other wise exist constitutes Medicare fraud (CMS, 2017). The False Claims Act (FCA) is the government’s primary litigation tool for recovering losses sustained as the result of Medicare fraud (Wiseman, 2017). In 2014, FCA recovery reached an all time high of $6 billion dollars (Wiseman, 2017). To establish liability under the FCA, four elements must be met. These elements include, a false statement or fraudulent course of conduct, that it was carried out with the requisite of scienter, that the government’s decision was to pay out the claim, and that it caused the government to pay out the money (Wiseman, 2017). Scienter requires that the defendant knew that some law was being violated (Wiseman, 2017). Sam’s time as a Nurse Practitioner (NP) is being coded and billed to Medicare as …show more content…
From this case study, we are not able to determine if the independently owned physician primary care office is already aware of this error. Consequently, the determination if voluntary disclosure would apply to the physician primary care office is not possible. I recommend that Sam promptly report this violation. To report this violation, Sam can call the Medicare and Medicaid Fraud Reporting Center or can submit a report directly online at www.medicarefraudcenter.org (Medicare & Medicaid Fraud Reporting Center,
Medicare fraud can cost taxpayers billions of dollars and places the health and welfare of Medicare beneficiaries at risk (CMS, 2017). Both over-coding and under-coding constitute Medicare fraud (Dillon & Hoyson, 2014). Knowingly billing for services at a level of complexity higher than services provided or documented in the file creates Medicare fraud (CMS, 2017).
Knowingly submitting, or causing to be submitted, false claims or making misrepresentations of fact to obtain a federal healthcare payment for which no entitlement would other wise exist constitutes Medicare fraud (CMS, 2017). The False Claims Act (FCA) is the government’s primary litigation tool for recovering losses sustained as the result of Medicare fraud (Wiseman, 2017). In 2014, FCA recovery reached an all time high of $6 billion dollars (Wiseman, 2017). To establish liability under the FCA, four elements must be met. These elements include, a false statement or fraudulent course of conduct, that it was carried out with the requisite of scienter, that the government’s decision was to pay out the claim, and that it caused the government to pay out the money (Wiseman, 2017). Scienter requires that the defendant knew that some law was being violated (Wiseman, 2017). Sam’s time as a Nurse Practitioner (NP) is being coded and billed to Medicare as …show more content…
From this case study, we are not able to determine if the independently owned physician primary care office is already aware of this error. Consequently, the determination if voluntary disclosure would apply to the physician primary care office is not possible. I recommend that Sam promptly report this violation. To report this violation, Sam can call the Medicare and Medicaid Fraud Reporting Center or can submit a report directly online at www.medicarefraudcenter.org (Medicare & Medicaid Fraud Reporting Center,