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March 21, Author: An analysis Introduction One of the most pressing issues affecting the health sector is Medicare fraud. Based on the events that rocked the health communitywhich involved Columbia Health HospitalsAmerica has decided that it is high time to pay closer attention to one of the reasons why the Medicare is bleeding to death.
This will try to look into the events that shaped the most controversial and biggest Medicare scandal that has awakened government to act before it is too late. To do so we will need to first define what fraud is and how it is particularly committed. At issue were allegations that Columbia had defrauded Medicarethe deferral health insurance for the elderly and the disabled Medicare was created by Congress in as a means to provide health benefits to Americans over the age of 65 and for the seriously disabled In the beginningit was said that Medicare had no effective cost control and while it did help the people it was meant to help i.
In the beginninghospitals were reimbursed on a cost plus basis meaning that Medicare paid for the cost of service plus a fee for administrative overhead HoweverinCongress passed the first significant effort to curb the skyrocketing costs of Medicare.
Congress adopted a payment system based on diagnostic related groups DRGs.
Under the DRG system hospitals would be paid per admission with an amount determined by the diagnosis instead of per day or per service. This new system helped check increasing Medicare costs but it also hurt hospitals and made them bleed profusely -at least on financial aspect.
Among these were upcodingcost shiftingunethical practices to pressure acquisition targetsand financial relationships with doctors Analysis First things first: When does one commit fraud? The violator may a physician or other practitionera hospital or other institutional providera clinical laboratory or other supplieran employee of any providera billing servicebeneficiaryMedicare carrier employee or any person in a position to a claim for Medicare benefits Under the broad definition of fraud are other violationsincluding the offering or acceptance of kickbacksand the routine waiver of co-payments According to the Find Law websitefraud schemes range from those perpetrated by individuals acting alone to broad-based activities by institutions or groups of individualssometimes employing sophisticated telemarketing and other promotional techniques to lure consumers into serving as the unwitting tools in the schemes.
Seldom do perpetrators target only one insurer or either the public or private sector exclusively.
Doctors were given the opportunity to become shareholders in the company -thus giving motivations to physicians to refer patients to its hospitals instead of its competitors. Moreoveras shareholders of the hospitaldoctors had more incentives to hold down costs or to comply with managerial directives It isthusnot surprising to see how fraud could happen in such an environment.
While this may not be a bad gesture in the over all scheme of thingsit still says a lot about the ethics of Columbia management. It would seem that the managers and doctors have lost the essence of their profession. Let me qualify that there is nothing evil in wanting to work for money.
What constitutes evil is applying fraudulent means to get more profit Now that we have an idea of what the problem is and where it liesone recommendation that can be forwarded is the strengthening of ethics and values formation in the medical community. Doctors as well as everyone involved in the medical profession should understand that medicine is a callinga vocation where money should come secondary to quality health care Second recommendation would be to pressure government into providing stricter procedure for health careparticularly for Medicare.
As noted by the Concord Coalition websitewherever medical guidelines are hazy and judgment calls are requiredit tries to ration claims through arbitrary rulescreating a feast-or-famine reimbursement policy.
It imposes huge compliance costs and produces capricious results. Worst of alldespite the estimated 45pages of regulationsthe system careens toward bankruptcy as costs keep rising Concord Coalition More importantlyit is important to set harsher penalties for Medicare fraud cases.
The purpose of this is to heighten awareness of the problem affecting our health care industry with the ultimate goal of finding the perfect solution to the problem. Needless to say Medicare fraud hurts not just the beneficiaries or the members but the taxpayers in general.
In additionwe have learned from the case presented to usthat there is still need for improvement in terms of implementing the Medicare system.
More importantlywe have seen that ethics plays a huge part in the Medicare scandal. It is the belief of this author that a strengthening of ethics formation in the medical community will help in changing the tides of Medicare fraud References Find Law Medicare Definition of Fraud [online] Available at: June 14] Kansas Medicare Medicare Fraud [online] Available at: June 14] Medicare June 14] Mutual Medicare June 14] Senior Health June 14] The Concord Coalition A SymptomNot the Disease [online] Available at: June 14] United Government Services Fraud and Abuse [online] Available at: June 14] PAGE.Case Study: Columbia / HCA and the Medicare Fraud Scandal Central Facts of the Case X In , Columbia/HCA Corporation was the largest health care company in the world X In , Columbia Hospital Corporation was named the ¡§Most Admired Company¡¨ by Fortune magazine.
Dear Twitpic Community - thank you for all the wonderful photos you have taken over the years. We have now placed Twitpic in an archived state. May 16, · We have posted a number of times, (most recently here, and see links to earlier posts) about the RBRVS Update Committee's (RUC) responsibility for Medicare's relatively poor payme.
Case Study: Columbia / HCA and the Medicare Fraud Scandal Central Facts of the Case?X In , Columbia/HCA Corporation was the largest health care company in the world.
Download-Theses Mercredi 10 juin As a civil wrong. In common law jurisdictions, as a civil wrong, fraud is a regardbouddhiste.com the precise definitions and requirements of proof vary among jurisdictions, the requisite elements of fraud as a tort generally are the intentional misrepresentation or concealment of an important fact upon which the victim is meant to rely, and in fact does rely, to the harm of the victim.