Article 1: Becker, D., Kessler, D., & McClellan, M. (2005). Detecting Medicare abuse. Journal of Health Economics, 24(1), 189–210.
This research was initiated through a collaboration of authors from the University of California in Berkeley, Stanford University, and the Centers for Medicare and Medicaid Services. The purpose of the research was to determine the effect of Medicare law enforcement on hospital and patient billing. The authors note an increase in Medicare fraud and abuse in the recent past. However, this article reports that there is a dearth of evidence regarding the impact of law enforcement efforts on these crimes. Additionally, there is scanty evidence on the effect of the law enforcement on the quality and cost of healthcare.
According to the authors, majority of past research investigates Medicare abuse and fraud based on audit data, which is costly. In this regard, the current research utilizes a longitudinal research approach. Specifically, the authors focus on elderly Medicare recipients who utilized health services from 1994 to 1998. The sample included patients with one or more illnesses that were susceptible to Medicare abuse. In addition to the patient’s data, the study also looked at the claims data associated with anti-fraud enforcement procedures in different states, death records, and hospital features. The analysis involved a comparison of patient data and the expenditures of the Medicare Fraud Control Units (MFCU’s).
The investigation revealed that increased Medicare law enforcement results in low billings for both patients and hospitals. Moreover, the study concluded that the lower billing did not have negative impacts on the health outcomes of the patients. Generally, this research provides an understanding on the impact of the existing Medicare enforcement laws on the cost and quality of healthcare.
Article 2: Price, M., & Norris, D. M. (2009). Health care fraud: Physicians as white-collar criminals? The Journal of the American Academy of Psychiatry and the Law, 37(3), 286–289.
Dr. Price and Dr. Norris from the department of psychiatry in the Harvard Medical School in Boston wrote this editorial. This article argues that healthcare abuse and fraud should be treated like any other white-collar fraud. Similar to white-collar crimes, healthcare frauds are characterized by deception and cover-ups in the absence of violence. According to the authors, many organized criminal groups have been reported to engage in healthcare frauds over the years. In this view, treating the healthcare frauds and abuse as white-collar crimes will enable the government and the victims to get the justice that they deserve.
This article involves an analysis of past literature to support the statement that healthcare fraud is a white-collar crime. The research outlines several forms of healthcare frauds that include; exaggerating the severity of diseases, billing discrepancies, provision of excessive treatments, and accepting kickbacks among others. In their assessment, the authors reveal that Medicare and Medicaid crimes have failed to elicit attention from the media and the public. This is contrary to the impact that white-collar frauds have caused. The analysis also notes that healthcare frauds affect three to ten percent of the total federal healthcare budget.
This article will be very beneficial in the research because it provides evidence on the incidences of healthcare fraud over the years. Moreover, the authors have given information on the efforts made by the Obama administration to curb the Medicare and Medicaid fraud. Lastly, the article identifies the institutions involved in detecting and investigating healthcare fraud in America.
Article 3: Pande, V., & Maas, W. (2013). Physician Medicare fraud: Characteristics and consequences. International Journal of Pharmaceutical and Healthcare Marketing, 7(1), 8 – 33.
Pande and Maas (2013) are researchers from the University of Wisconsin, and acknowledge that healthcare fraud in the United States has become a national epidemic. Despite the efforts by the federal to combat healthcare fraud, many incidences are never detected. In this regard, the authors note that one cannot be certain on the amount of money lost through these fraudulent activities. The objective of this article is to determine the features of physicians convicted of healthcare fraud and abuse. The research also determines the actions taken against these physicians.
The names of the physicians convicted of healthcare fraud were obtained from the Office of the Inspector General. In reference to Pande and Maas (2013), this office contains a database of all the physicians excluded from future government-funded healthcare programs. The authors cross-checked the names with other public records for verification purposes. Their demographic characteristics and the kind of fraud that they engaged in were also outlined.
Based on the findings of the current research, majority of the convicted physicians were male (87%). The mean age of the physicians was above 58 years and majority (59%) included family practitioners and psychiatrists. Each physician was responsible for fraud amounting to 1.4 million dollars on average. Interestingly, 37 percent of the convicted doctors did not face jail time. This paper will provide perspectives on the characteristics of physicians involved in Medicare fraud and abuse. It also provides evidence that more strict penalties are required to deal with the increasing reports of healthcare fraud.
Article 4: Toothman, M., Moore, K., & Lee, D. (2011). Unraveling Medicare and Medicaid prescription drug Fraud and abuse. Compensation and Benefits Review, 43(6), 339–345.
Toothman, Moore, and Lee (2011) from Pressley Ridge Grant Gardens, Cancer Service Line, and Marshall University undertook this research. The authors note the uncertain future of Medicare and Medicaid due to increasing cases of fraud and abuse. The purpose of the article is to provide solutions to curb the current incidences of Medicare and Medicaid crimes that occur through drug prescription. Specifically, the authors concentrate on the Integrated Data Repository approach for the detection of such frauds. This research is important as many fraudulent physicians cost the healthcare sector billions of dollars through drug prescriptions.
The article is a literature review of scholarly sources relating to the study objective. The authors also acknowledge the dearth of research regarding drug prescription frauds. Such frauds occur through drug purchasing arrangements, discounts, kickbacks, and pharmaceutical marketing. The article also provides an expert opinion on the Integrated Data Repository program, which requires all claims to be submitted to the Centers for Medicare and Medicaid Services (CMS) to prevent payment of such swindles.
As a result of the unavailability of data on Medicare and Medicaid drug prescription fraud, policy makers are unable to curb all fraudulent activities in healthcare. The analysis reveals that the introduction of the Integrated Data Repository approach will be able to curb majority of fraud relating to drug prescription. This research provides an understanding of the efforts made by the government to enforce healthcare anti-fraud laws. It also outlines the kind of frauds and abuse that related to drug prescription.
Article 5: Rudman, W. J., Eberhardt, J. S., Pierce, W., & Hart-Hester, S. (2009). Healthcare fraud and abuse. Perspectives in Health Information Management, 6(4), 1-24.
This research was undertaken through a collaboration of the AHIMA Foundation Policy and Research Institute, University of Mississippi, DecisionQ Corporation, and the Mississippi Institute for the Improvement of Geographic and Minority Health. At the beginning of the article, the authors provide various examples indicating the level of fraud reported by the Department of Justice and Fraud in 2007. Based on their analysis, healthcare fraud accounts for about 15 percent of the federal healthcare budget. However, the authors acknowledge that there are discrepancies in the total loss projections, as many cases are not detected. The aim of the research is to give an in-depth understanding of all issues that relate to healthcare fraud in the United States.
This research constitutes a literature review of studies that relate to healthcare fraud and abuse. The authors have given an elaborate definition of fraud and abuse and offers solutions for investigating the two aspects in healthcare. In addition, this research outlines the most common types of Medicare and Medicaid abuse and their implication on public finances. Lastly, the researchers offer various data mining models that are crucial in detecting fraud in Medicare and Medicaid.
This article will be critical in the literature review section of the research as it offers definition of various terms related to healthcare fraud and abuse. It also provides information on the importance of investigating healthcare fraud at the physician and organizational levels. Moreover, it concludes that all the stakeholders in the health sector must provide the required documentation and take a moral stand against Medicare and Medicaid abuse.
Article 6: Gasquoine, P. G., & Jordan, T. L. (2009). Medicare/Medicaid billing fraud and abuse by psychologists. Professional Psychology: Research and Practice, 40(3), 279–283
Gasquoine and Jordan (2009) from the University of Texas–Pan American and Corpus Christi, Texas undertook the current research. The authors outline various laws that can convict Medicare and Medicaid fraud offenders. Although there have been few cases of psychologist’s participation in healthcare fraud, they seem to be the main target of the government crackdown. This crackdown is aimed at uncovering irregularities related to healthcare abuse and fraud. The aim of the current research is to determine the kind of Medicare and Medicaid abuse caused by psychologists. The research also looks at the various ways that independent psychologists can become unintentionally involved in healthcare fraud.
The authors have employed a literature review approach to collect the necessary information for the study. According to the research, psychologists lack information on the actions that amount to healthcare fraud, and often find themselves in the middle of government probes. Some of the issues that predispose them to probes include; ignorance of claim processing processes, unintentional billing fraud, and lack of knowledge or ignorance on the changing guidelines. The authors also note that state psychology licensing boards hardly investigate fraud and abuse among their staff. Therefore, Psychologists are most likely to participate in these crimes due to the lack of supervision and inspection by the licensing boards.
The article will provide an illustration of the factors that subject particular medical professionals (psychologists) to healthcare fraud and abuse. It also provides an understanding of the mechanisms used by the federal government to detect fraud and abuse in healthcare; whistle bowing and statistical detection.
Article 7: Sanchez, M. (2012). The role of the forensic accountant in a Medicare fraud identity theft case. Global Journal of Business Research, 6(3), 85-92.
Sanchez (2012) is an accounting professor at Rider University and her research focuses on identity theft in Medicare fraud. In reference to the article, identity theft is one of the most common crimes in America and occurs when another person for financial gain impersonates a person’s identity. The research provides an example of a previous case on identity theft in Medicare and outlines its implications. Moreover, the author focuses on the role of forensic accountants in unveiling such cases.
The research presents a review of previous literature on the topic under study. It also examines different forms of identity theft that are likely to occur in healthcare fraud and discusses the most common forms of Medicare abuse and fraud. In addition, there is a case study presented in the article regarding a 35 million dollar fraud based on identity theft. According to the author, forensic accountants play a critical role in the investigation of Medicare fraud. In this view, the authors explain the role played by forensic accountants in investigating the 35 million dollar-fraud case.
This article provides and understanding of identity theft as one of the forms of Medicare fraud. Furthermore, it enables the researcher to comprehend the basic concepts that relate to healthcare fraud and abuse. The presentation of a case study also enhances the researcher’s understanding of how healthcare fraud and abuse investigations are carried out and the factors that influence the outcome. However, the article is biased as it only focuses on one case and one aspect (identity theft) of Medicare fraud.
Article 8: Ignatova, I., & Edwards, D. (2008). Probe samples and the minimum sum method for Medicare fraud investigations. Health Services and Outcomes Research Methodology, 8(4), 209–221
The research was undertaken through a collaboration of the California Polytechnic State University and the University of South California. The focus of the article is the statistical techniques used to investigate suspicious billing in Medicare fraud. The random sampling method of the total claims has been in use for a long time. However, the authors note that the method is flawed and biased and results in spurious outcomes. In this regard, the authors propose a two stage sampling method that ensures that both samples are analyzed and the results compared. Therefore, the objective of the research is to compare the effectiveness of the two techniques in Medicare billing fraud investigations.
The authors reviewed past literature on the statistical techniques used in calculating Medicare billing. In addition, the authors have incorporated calculations that compare the effectiveness of the two techniques. According to the article, the minimum sum method is the conventional technique used to calculate discrepancies in billing. It applies a random sample of claims and the investigators calculate the difference between the overpayment and the actual amount that was to be paid. Unlike the minimum sum technique, the two-stage technique is able to capture what the first sample missed and vice versa.
This article provides the researcher with a statistical perspective on Medicare fraud investigations. The study also provides an in-depth understanding of the formula and techniques used to calculate billing fraud. The authors conclude that the two-stage technique is less biased and should be considered during investigations.
Article 9: Harrington, K., Allen, A., & Ruchala, L. (2007). Restraining Medicare abuse: The case of upcoding. Research in Healthcare Financial Management, 11(1), 1-25.
This research was conducted through a collaboration of authors from Southwestern Adventist University and University of Nebraska. The article defines upcoding as a procedure that healthcare institutions use to categorize patients into Diagnosis Related Groups (DRG’s). This enables them to get higher reimbursement from Medicare funding which is a form of fraud. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 was established to deal with such cases. The purpose of this research is to investigate the effectiveness of HIPAA in combating upcoding. The research also investigates the prevalence of upcoding in hospitals and the factors that affect reduced upcoding following the establishment of HIPAA.
The authors reviewed past literature on the topic and undertook a survey across 1,777 hospitals in the United States. One major findings of the research was that most of the hospitals violated patients who were reliant on Medicaid and Medicare. Moreover, for-profit hospitals exercised upcoding more than government institutions. The authors also indicate that HIPAA had reduced the incidences on upcoding. However, the research acknowledges that more law enforcement efforts are required to eliminate upcoding in health facilities.
There are many laws that have been introduced in the past to curb healthcare fraud in the United States. This article gives an insight on the effectiveness of the HIPAA law, and will provide an understanding of the efforts made by the government in dealing with these crimes. It will also enable the research to understand the factors that limit the law enforcement efforts in Medicare fraud and abuse.
Article 10: Rabecs, R. N. (2006). Healthcare fraud under the new Medicare part D prescription drug program. Journal of Criminal Law and Criminology, 96(2), 727-756.
The author is affiliated with the Northwestern University School of Law. The article gives information about the billions of dollars that have been lost in the past through Medicare fraud in America. The author notes that the Medicare drug prescription program introduced in 2006 is likely to increase the incidences of fraud in the future. The programs afford the beneficiaries an opportunity to receive reimbursement for drugs prescribed on outpatient basis. The purpose of this article is to assess the kinds of frauds that may arise through the Medicare part D drug prescription program.
The author reviews existing literature on the Medicare drug prescription programs and the effectiveness of the existing laws in combating drug prescription fraud. The author also outlines the role of pharmacists and pharmaceutical companies in violating part D of the Medicare plan. Based on the findings, the federal government has heightened its investigations on Medicare Fraud due to the loopholes provided by Part D program. The anti-kickback statute proves to be effective in limiting the violation of the drug prescription program. Moreover, the statute will enable pharmaceutical companies to comply with the guidelines of the Medicare program. However, the authors note the need to structure the waivers offered by these companies to comply with the regulations stipulated by the Office of the Inspector General.
This article will enable the researcher to understand the programs under the Medicare program with a specific focus on part D. It will also promote understanding of other components of the Medicare programs and the impact of drug prescription programs on the level of fraud.
References
Becker, D., Kessler, D., & McClellan, M. (2005). Detecting Medicare abuse. Journal of Health Economics, 24(1), 189–210.
Gasquoine, P. G., & Jordan, T. L. (2009). Medicare/Medicaid billing fraud and abuse by psychologists. Professional Psychology: Research and Practice, 40(3), 279–283.
Harrington, K., Allen, A., & Ruchala, L. (2007). Restraining Medicare abuse: The case of upcoding. Research in Healthcare Financial Management, 11(1), 1-25.
Ignatova, I., & Edwards, D. (2008). Probe samples and the minimum sum method for Medicare fraud investigations. Health Service Outcomes and Research Methodology, 8(4), 209–221.
Pande, V., & Maas, W. (2013). Physician Medicare fraud: Characteristics and consequences. International Journal of Pharmaceutical and Healthcare Marketing, 7(1), 8 – 33.
Price, M., & Norris, D. M. (2009). Health Care Fraud: Physicians as white-collar criminals? The Journal of the American Academy of Psychiatry and the Law, 37(3), 286–289.
Rabecs, R. N. (2006). Healthcare fraud under the new Medicare part D prescription drug program. Journal of Criminal Law and Criminology, 96(2), 727-756.
Rudman, W. J., Eberhardt, J. S., Pierce, W., & Hart-Hester, S. (2009). Healthcare fraud and abuse. Perspectives in Health Information Management, 6(4), 1-24.
Sanchez, M. (2012). The role of the forensic accountant in a Medicare fraud identity theft case. Global Journal of Business Research, 6(3), 85-92.
Toothman, M., Moore, K., & Lee, D. (2011). Unraveling Medicare and Medicaid prescription drug fraud and abuse. Compensation and Benefits Review, 43(6), 339–345.