Medical Crime

Medical Crime is an illegal action in medical profession which led towards Health Care Fraud and Health Care Abuse. U.S Food and Drug Administration (FDA) has instigated every healthcare crime and fraud very seriously and penalties are too levied thereon for restraining such immoral medical occurrence in future.

Part A Health Care Fraud
Health Care Fraud is defined as the misrepresentation of factual informationwhichis stated intentionally for means of unfair profit that is gained through medical coverage under the Medicare Program. It is an illegal claimof medical expenses which is misstated by an individual or organization that leads to unauthorized benefit.

Difference between Health Care Fraud and Health Care Abuse
Health Care Fraud is defined as an intentionalact of misstatement with havingperception that something is wrong and is done for the purpose of undue profit or unauthorized payment whereas, Health Care Abuse is described as an inconsistent act or unreliable actionin medical or fiscal practices. It involves unnecessary treatments and excessive payments in addition to an actual program payment which can be enforced directly or indirectly.

The leading difference between healthcare abuse and healthcare fraud is the intention of a person.Its actions are quite effective as it grabs the valuable funds of the Medicare Trust which can indeed, be utilized for the betterment and treatment of Medicare beneficiaries.

Part B Ten Examples of Medical Crime  Fraud
The following are the ten examples of medical crime  fraud
Unfurnished billing for services rendered
Misstatement of actual treatment to adjust payment

Proposing or getting bribe
Issuing certifications for the coverage of medical expensesor falsifying the medical archives to adjust payment
Billing for unfurnishedservices in addition toactual treated diagnosis e.g. upcoding

Charges of exploding or unbundling
Provision of unnecessary medical services e.g. durable medical equipment or therapy services
Favoritism of multiple chronic treatments which will not be recovered by patients such as diabetes and hypertension

Benefit sharing with others e.g. ping ponging
Usage of rogue nurses or doctors.

Part C Four Medical Crime  Fraud Cases
The following are the four medical cases related to the healthcare crime  healthcare fraud
First Medical Fraud Case In November 2009, Mark Kabins, Orthopedic Surgeon was convicted in fraud case misprision of felony. The Board of Medical Examiners of the state accused Kabins of fraudulent act led to profession into disrepute. He was been charged for not reporting criminal activity. Kobins was sentenced for five years probation by the U.S District Senior Judge Justin Quackenbush. Medical Boards complaint states that Kabins admitted the concealing of wire fraud which were been conducted by others medical professionals on his former patient. Plea agreement needs Kobins to pay US 3.5 million and perform 250 hours of community service to his former patient (Melodie Simon) who suffered paraplegic due to an operation conducted by Kobins and another surgeon.

Second Medical Crime Case Gayle Rothenburg, M.D. was the operator in the Center for Image Enhancement in Houston, Texas. According to the investigation held by FDA, Rothenburg injected patients (over 170) with unauthorized drugs by mentioning it as the authorized Botox Cosmetic. He was charged as indicted for mail fraud, misrepresenting a federal agent, misbranding a drug and was finally sentenced for 27 months in prison with fine of 1,000 (restitution of 98,426).

Third Medical Fraud Case In July 2009 in California, twenty people violated Medi-Cal fraud scheme of 4.6 million. These people conducted a healthcare nursing program for disabled at their homes. Around 75 patients with developmental disabilities and cerebral palsy were in school or home. Out of twenty, some were unlicensed few were nor properly trained and while others were no medical training at all. These twenty people are amid 42 defendants who were being classified in 41-count indictment. According to Thomas OBrien, it was the first ever case alleging Medi-Cal fraud in the history of California.

Fourth Medical Fraud Case Michael Clair, Dentist, was accused in Medicaid fraud case in Massachusetts. He was alleged for using paper clips in patients root canal whereas the procedural dentistry requires the usage of stainless steel posts for the safety of patients. Clair pleaded not guilty and was released on personal grounds. He was charged for larceny, illegally prescribing drugs, assault and battery and with defrauding Medicaid of 130,000. According to prosecutors, Clair was suspended in 2002 by Medicaid but he continued his profession by using names of other dentists from August 2003 till June 2005. Additionally, Massachusetts record shows that Clair was already been suspended in three states for practicing his profession in which he used to perform unnecessary root canals.

Part D Recommendations
The following are the five recommendations through which people can help in preventing healthcare crime  fraud

Reading Own Benefit Statements Explanation of Benefits statement is issued after the treatment which should be read carefully to ensure that health insurance plan has made the payment for the actual treatments received. Further, incase of any discrepancy in the payment, error should be reported accordingly.

Beware of Free Medical Treatment Community service organizations occasionally propose free medical treatments such as blood pressure, dental treatment, screening of vision, etc. through which, the fraudulent people attempt to get names and insurance number of patients for onward use in fraudulent billings.

Protection of Health Insurance Information Health Insurance Card is used to pay the cost for the medical treatment, just like credit card is used to pay the cost therefore, people should never disclose their insurance information to healthcare solicitors as well as to others on phone.

Reporting Suspicious Frauds to BCBSA People should report any suspicious fraud directly to the BCBSA at their toll-free hotline, 1-800-877-BLUE which is primarily been set up for reporting healthcare fraud  crime without limitation of insurance coverage or affiliation.

Investigation  Perception People can help prevent healthcare crime  fraud by inquiring detailed information from medical providers incase of any confusion, doubt or hesitation in acknowledging  signing written forms and statements. Perception is too helpful for people to prevent such illegal activities, thus, people should periodically browse the Anti-Fraud Website (www.bcbsa.comantifraud) which contains updated information and facts regarding the healthcare frauds.


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