Medicare Fraud Case Analysis

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In the U.S., 50 million people depend on the Medicare program for their health needs, and the taxpayers bear the burden of $600 billion per year to fund the program. Therefore, the program’s administration is compelled to curtail Medicare related fraud, abuse and wastage of resources that add up to about $58 billion annually – or approximately 10 percent of the budget. For the last two decades, Medicare fraud has infested the program like an incurable cancer with over $1 trillion compromised. With the ever-expanding complex program, how would it be possible to develop and use a range of tools as a panacea to increase an oversight and scrutiny that would eventually lead to proper and efficient use of scarce resources in the future?
In the article
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legislators assert on Medicare’s administrators, since it is a public entity. Legislators have significant stakes associated with the health care industry. The health care industry as a whole spend huge sum of money on campaign contributions, lobbying in Washington, as well as contributing directly to the representatives’ local community by operating facilities and hiring from within. Therefore, when the investigators are assessing the provider’s financial records, legislators have to step in to pressure the administrators to back off as it occurred in the Riverside General Hospital. When the investigators uncovered misdeeds by the governing body at the hospital and decided to hold off the funds, an elected official approached them and used its sway to pressure Medicare’s administrators to reverse the course as stated by Christopher S. Stewart in the article “Hospitals, Other Providers Seek help from Elected Officials.” The pressure on occasions has compelled the Medicare’s own legal counsel to interpret their powers narrowly, restricting them to instances where providers were clearly engaged in fraud. A law should be enacted that would prohibit the legislators from intervening during the duration of the investigation, and administration should be granted autonomy to investigate the cases without …show more content…
As stated in another article published in the Wall Street Journal “How Medicare ‘Self-Referral’ Thrives on Loopholes,” by John Carrayou. The author claims that although outlawed since the early 1990’s, self-referral has become a common practice among many U.S. physician groups, which refer any tests to entities from which they benefit financially. It is done through exploiting an exception to the law in ways its writer did not anticipate. He further underscores the cases of two providers, 21st Century Oncology and Halifax Hospital Medical Center. 21st Century Oncology and Halifax Hospital Medical Center both exploited the self-referral loophole by setting up multiple facilities, and their physicians referred the patients to one of their own clinics to carry out tests that were not necessary most of the time. 21st Century Oncology has reached a settlement with the regulators without any public disclosure. On the other hand, Halifax Hospital Medical Center has paid out $85 million in penalties and fines to the regulators. In order to curb the misuse, the outdated Medicare law’s language must be revised thoroughly to meet the standards that would close the loopholes, and ultimately put an end to the

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