Healthcare fraud, abuse, and waste constitute more than 30% of annual health expenditures in the United States. A wide range of fraud cases are caused by dishonest providers, colluding patients, organized crime, dishonest employees, and deliberate attempts of patients to qualify for healthcare benefits ( Adomako, 2017) . The problem still persists despite the growing concerns to intensify efforts in curbing Medicaid fraud and abuse, causing an increase in healthcare delivery cost in the US. This paper presents a Medicare fraud and abuse management plan. The plan includes a real-world case of Medicare fraud and abuse.
Case Study
Lawrence Young, a Detroit-area podiatrist was arrested in April 2017 by law enforcement officials for his role in a $13.9 million healthcare fraud scheme. He admitted engaging in a fraudulent scheme between 2010 and 2017 to defraud Medicare program ( Department of Justice, 2018) . Young applied for Unna Boot to Medicare by submitting fraudulent and false claims. The Unna Boots are medicated dressings applied post-surgery in controlling swellings of the foot or leg. He regularly submitted the claim for reimbursement with the knowledge that his clients only received dressings that were not medicated.
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Young provided false information to his podiatry patients for his own benefits. He convinced them that they needed to prevent developing hammertoes through minor surgeries and weekly and bi-weekly shots. Allegedly, the surgeries and shots were not medically necessary. As a result, the clients returned to his practice regularly for minor surgeries and shots. Moreover, he allegedly billed Medicare for other services that were never rendered and medical devices never given to patients. Young was sentenced to two and a half years in prison for Healthcare fraud. He was also ordered to pay reinstitution of $337,907 to the health department in the US and to forfeit the same amount. The case was investigated by the HHS's office of the inspector general and the FBI.
Young’s Case Analysis
Ethical Principles
Lawrence Young defiled the ethical principals in his conduct by violating the Medicare law. Physical therapists’ code of ethics, regardless of association membership offers guidelines for ethical practices regarding business practices such as fraud, abuse and waste, and documentation (Wharton, 2018) . The code of conduct contains links in standards or principals 5, 7, and 8. The ethical responsibility violated by Young can be found in standard/principle 5, mandating therapists to fulfill their professional, ethical, and legal obligations. Section 5A states that therapists must ensure compliance with federal, state, and local regulations and laws.
The standard/principle 7 provides directions to physical therapists to support and promote business practices and organizational behaviors that bring benefits to patients and society. The 7B principle expects them to seek reasonably and deserved remunerations for services. The 7E principle expects physical therapists to have awareness of charges and ensure accuracy in service coding and documentation reflecting the extent and nature of the provided services.
The standard/principle 8 of the code addresses physical therapists to responsibly meet individuals’ healthcare demands, while section 8C directs them specifically to ensure health care resources’ stewardship. The principle, in essence, obligates physical therapists to avoid fraud, abuse, and waste.
Legal Implications
Lawrence Young broke the law by conducting a Medicare fraud by knowingly submitting a claim to obtain Medicare payment without entitlement. He committed Medicare abuse by billing for unnecessary medical services. Young violated the False Claim act that provides protection to the government against being overcharged. He submitted payment claims to Medicare with the knowledge that it was fraud or fraudulent.
Lawrence Young also violated the anti-kickback statute. The statute prohibits the willful and knowing payment of remuneration to reward referrals of clients or generate business involving items or services payable by the Medicare programs (CMS, 2017) . Young was an attractive target for kickback scheme because he decided what drug the patient could use, the specialist they see, and the healthcare supplies or service they receive. He lied to his patients that they needed to prevent hammertoe through weekly and bi-weekly minor surgeries and shots.
Young violated the criminal health care fraud statute. The statute focuses on the prohibition of wilful or knowingly attempts to execute, or executing artifice or scheme (CMS, 2017) . He defrauded health care benefits programs around $13.9 million.
Policies and Procedures to Prevent Medicare Fraud and Abuse
The policy I would develop to prevent cases similar to Young's occurring in the future is a compliance plan for fraud and abuse prevention, detection, investigation, and reporting. The policy will ensure compliance with applicable laws and regulations pertaining to fraud and abuse in state and federal health care benefit programs and dissemination of information to its members of the workforce regarding such regulations and laws. All staff involved in healthcare, as well as billing, are responsible to abide by the Medicare program federal requirements. The responsibility of the developed policy is to have healthcare and prescription billing processes that do not contribute to fraud and abuse.
The procedures of preventing Medicare fraud and abuse include training and educating the workforce members and contractors as necessary to promote compliance with regulatory and legal requirements related to fraud and abuse. The procedures involve the participation of healthcare staff and billing staff in at least one hour of documented training covering a review of general services administration and the office of inspector general, and exclusion lists for every provider and staff on annual basis, without allocation of federal exclusions. The training also covers reviews on ways of preventing Medicare fraud, waste, and abuse and actions to take when fraud is detected. Moreover, policy in place for investigation and reporting will be reviewed, and practitioners and staff will sign a yearly conflict of interest statement. The Medicare prescription coverage and individuals' rights notice will be posted visibly in the counseling rooms, pharmacy, and waiting area among other places.
Medicare Fraud and Abuse Prevention Mechanisms
Fraud and abuse are classifications of improper payment in errors in government healthcare assistant programs. The investigators of fraud and abuse typically rely on corruption and asset misappropriation by conducting an analysis of big data generated by healthcare transactions. The specific prevention mechanisms for cases similar to that of Lawrence Young involves the inclusion of technology, clinical audits, and investigative capability components in the solution.
Technology
Compliance with fraud and abuse regulations entails connecting health plans with large data volumes. Technology can be essential in processing large data volumes in the identification of patterns and anomalies more effectively than human beings. Effective technology solutions for fraud and abuse can assist Medicare organizations and health plans for risk identification, documentation, audit preparations, referrals, and reporting.
Clinical Audits
Programs focusing on preventing fraud and abuse need to effectively conduct clinical audits. The audits give Medicare organizations the potential of reviewing potential fraud and abuse allegations. The audits are effective in determining whether medications and diagnosis, among others, are worthy of further investigation (Claris, 2018) . The clinical audit programs benefit health plan by preventing improper payments from occurring and connects payers and providers in real-time to reduce abrasion by providers.
Investigation Capability
Non-compliance in Medicare programs should be prevented by arming payers and health plans with a strong investigative arm. The capabilities to investigate enables reporting of fraud schemes directly to the relevant authorities and provides evidence that protects or support health payers in case fraud is suspected. The evidence and documented fraud, waste, and abuse processes within health insurance organizations prove invaluable when a crime is taken to court.
Reference
Adomako, G. (2017). Strategies in Mitigating Medicare/Medicaid Fraud Risk.
Claris. (2018). Ways to Prevent Medicare Fraud Waste and Abuse. Retrieved from https://www.clarishealth.com/blog/3-ways-to-prevent-medicare-fraud-waste-and-abuse/
CMS. (2017). Medicare Fraud & Abuse: Prevention, Detection, and Reporting. Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/fraud_and_abuse.pdf
Department of Justice. (2018). Detroit Podiatrist Charged for Role in $13.9 Million Medicare Fraud Scheme. Retrieved from https://www.justice.gov/opa/pr/detroit-podiatrist-charged-role-139-million-medicare-fraud-scheme
Wharton, M. (2018). Ethics, Fraud and Abuse, and Professional Integrity A Commentary on “ Addressing PT’s Biggest Threat”. Retrieved from http://www.ppta.org/docs/default-source/ethics-newsletter-archive/Ethics_Fraud_and_Abuse_and_Integrity.pdf?sfvrsn=0
