Introduction
Fraud in the health industry takes many forms with some so casual that to an ordinary person it might not be recognizable yet it is openly done. The minor perpetrators of medical fraud include doctors, patients, physicians, and nurses while the major players in the corrupt game are health care providers. These big shots do it primarily for monetary benefits unlike the patients who do it for health purposes a reason that cannot be said for the nurses, doctors and physicians together ( Clark, & George, 2017) . Some proven ways in which corruption manifests itself in patients include; prescription drugs being used for purposes other than medication such as drug abuse, issuance of illness certificates in dishonest means, and exercising illegal ways to avoid paying for the medical services.
Pharmacists can participate in fraudulent deals through the recommendation of drugs to patients who don’t deserve. Other cases of fraud by medical practitioners involve medical errors during the payment for medical services like consultation, medical examination or services related to the resource ( Bauder, Khoshgoftaar, & Seliya, 2017 ) . The government loses a lot of money when health caregivers or contractors take part in corrupt practices which are mostly conducted through insurance blunders and deceit associated with foster and child care, home-based and community services, and lengthy period health care. And it is such cases of massive corruption that is discussed in this analysis.
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Governments Effort in Combating the Fraud
In 1996, the federal government passed a bill about the portability of health insurance and accountability which was under Public Law 104-191 with the aim of strengthening and consolidating the fight against medical fraud. Within the Act was an elaborate and comprehensive plan to tackle medical scam executed against each health plan, both private and public ( Oig.justice.gov., 2019) . The bill entailed the creation of a national program for controlling abuse and investigating Health Care Fraud. This program will be performing their joint duties via the Office of Inspector General under the guidance of the Secretary of the Department of Health and Human Services and the Attorney General. The national program is intended to harmonize law enforcement activities within States, Federal and local governments with regard to abuse and fraud in health care. The Act compels Health and Human Services and DOJ to describe in a report submitted annually, the sums appropriated and deposited to the Medicare Trust Fund, and their sources.
A strike force unit that comprised a mixture of experienced and aggressive officers from different law enforcement agencies was later formulated. The strike force was able to summon in court a total of 601 defendants from various federal states with varying counts of medical fraud. Licensed medical practitioners, doctors, and nurses were not left out of the dragnet, and their charges comprised even the prescription of hazardous sedatives such as opioids. Additionally, out of the thousands arraigned in court, those found guilty were banned from taking part in health care initiatives supported by the government, Medicare, and Medicaid ( The Department of Health and Human Services & the Department of Justice, 2006) . The perpetrators were charged with involvement in deceitful solicitations to private insurance firms, Medicaid, TRICARE, and Medicare for medical charges that were unwarranted or non-existent. The bulk of the deceitful conspiracies comprised beneficiaries, patient recruiters, and co-conspirators accepting cash giveaways for offering information concerning patients to the fraudulent parties who invoiced Medicare.
Miami Healthcare Fraud Scheme
Fifty-three-years old, Juliette Tamayo, president of Sunshine Medical Care Group, Inc. was also arraigned in court and charged with the medical fraud. The Miami based medical provider was detained after her association in a USD$ 3.7 million scam aimed to defraud Medicare through tendering of medical bills that were unwarranted and fabricated. Furthermore, she was not alone in the racket but in cohort with three other homes that she furnished with patient data from her facility expecting a kickback from the homes in question ( Treasury.gov., 2017 ) . Juliette took a guilty plea for her corruption in the wire con plan and a scheme to accomplish health care fraud. The Sunshine president is also purported to have conspired with other home health bureaus based in Miami in replacement of the provided instructions for drugs meant for home-based services for patients in her facility.
Other that were caught and paraded in court, in the countrywide sweep, by the law enforcement officers of the strike force comprises a patient recruiter from South Florida prosecuted for a medical scam worth USD$ 600,000. The South Floridian was charged with obtaining healthcare bribes in preference of transferring patients to Good Friends Services Inc. ( The Department of Health and Human Services & the Department of Justice, 2006). Ros Lazo was another guest to the officers carrying out the operation and was condemned to 87 months in jail and directed by the court to give compensation of USD$ 8.6 million. Ros was implicated in one of the largest Medicare rackets that involved the misappropriation of USD$8,603,859.
Billions Lost through Medical fraud
The strike force has done commendable work since its initiation in 2007 as it has successfully prosecuted nearly 4000 perpetrators. These individuals, who in their own ways have contributed to the fraudulent billing of Medicare to sums totaling USD$ 14 billion have all been jailed and others forced to pay restitution. Moreover, in the course of their investigation and consequent prosecution of the villains, the Strike Force indicted nearly 124 offenders from Florida only ( Ed.gov. 2019 ) . The total amounts of money associated with the fraud of these Floridians are estimated at USD$ 337 million. The Strike Force is commendable and has set an amazing accomplishment in the successful trial of healthcare- linked scam encompassing community mental health, HIV infusion, and home health.
References
Bauder, R., Khoshgoftaar, T. M., & Seliya, N. (2017). A survey on the state of healthcare upcoding fraud analysis and detection. Health Services and Outcomes Research Methodology , 17 (1), 31-55.
Clark, K., & George, A. (2017). Home Healthcare and the Medicare Fraud Strike Force. Home healthcare now , 35 (10), 549-553.
The Department of Health and Human Services & The Department of Justice, (2006). Health Care Fraud and Abuse Control Program Health Annual Report For FY 2005 -OIG .HHS .gov https://oig.hhs.gov/publications/docs/hcfac/hcfacreport2005.pdf
Ed.gov. (2019, January 31). Office of Inspector General. Retrieved March 7, 2019, from https://ed.gov/about/offices/list/oig/index.html?src=ft
Oig.justice.gov. (2019). USDOJ Office of the Inspector General. Retrieved March 7, 2019, from https://oig.justice.gov/
Treasury.gov. (2017, October 4). About OIG. Retrieved March 7, 2019, from https://www.treasury.gov/about/organizational-structure/ig/Pages/default.aspx
