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Recommended strategies to combat fraud are discussed at policy, practice, and grassroots levels. Health care practitioners, including pharmacists, can use these strategies to protect themselves and their patients from becoming victims of fraud or unknowingly committing fraud. Medicare and Medicaid are government-sponsored insurance programs with approximately 59 million Medicare and 72 million Medicaid beneficiaries.

Department of Health and Human Services, excluded health care providers and entities from serving federal health programs owing to fraudulent practices. Fraud increases the overall costs for vital health care services and can be harmful to patients. In fact, patients receiving medical care from health care providers who were subsequently excluded from Medicare for fraud had significantly higher rates of all-cause mortality and emergency hospitalization after risk adjustment.

In this case, it is important for providers to properly document any practice that may deviate from standard practice or from their usual billing codes. There is no standard in how fraud is classified. Medicare and Medicaid fraud can occur at the beneficiary patient or provider level and can be intentional or unintentional Table 1.

First, the FCA imposes civil liability on any person who submits, or causes to be submitted, a false or fraudulent claim to the federal government for payment or approval, either knowingly or owing to deliberate ignorance.

The AKS prohibits any person from knowingly or willfully offering, paying, soliciting, or receiving remuneration for making a referral to, or inducing business from, a federally reimbursed health care program. Last, the Physician Self-Referral Law Stark Law prohibits physicians from making referrals to certain designated health services paid for by Medicare or Medicaid. Specifically, referring patients to an entity in which the physician or immediate member of his or her family has ownership or investment interest or with which he or she has arranged compensation is regarded as a violation of the Stark Law.

Chief among these are fraud related to opioid prescription medications and pharmacogenetic testing. Genetic and pharmacogenetic testing has gained popularity in recent years, with more than medications now incorporating pharmacogenetic information in their drug labels.

Furthermore, the occurrence of fraud in this area is more prevalent among older adults; they have reported receiving unsolicited requests to receive random and high-cost genetic tests at senior centers, homes, or health fairs, and are often asked to provide their Medicare identification number to individuals who intend to use them for identity theft.

There are many comprehensive efforts to detect Medicare fraud. Prevention of Medicare and Medicaid fraud can be accomplished through several strategies at policy, practice, and grassroots levels.

Efforts to curb this fraud at the policy level can be especially useful in combating identity theft and drug diversion. New cards were disseminated to all beneficiaries last year, 44 and they were advised not to share their old or new Medicare number with unauthorized services.

Efforts focused on curbing drug diversion and associated fraud related to the FCA include prescribing and dispensing regulations, insurance formulary restrictions, manufacturer quantity limits, and restricted pharmacy allotments. At the practice level, health care practitioners can guard against billing and kickback-related fraud by doing due diligence.

For example, those who are looking to expand their practice and business can seek Advisory Opinions from either CMS or OIG, where practitioners can submit their detailed business arrangements for review of any possible violations of Medicare fraud at a reasonable cost. Pharmacists can provide objective information regarding health care plans without making recommendations, properly disclose the contract the pharmacy has, and train employees to ensure compliance. Regarding drug diversion and diversion-related fraud specifically, pharmacists can report suspicious prescribing activity to the Board of Medical Examiners in their state or local law enforcement.

Furthermore, protection against fraud can be facilitated using state Prescription Drug Monitoring Programs. These programs came about as a result of the Secure and Responsible Drug Disposal Act of an amendment to the Controlled Substances Act , 57 and they allow patients to safely dispose of expired or unused prescription opioids or other medications , thus removing the potential for diversion from home.

Regarding pharmacogenetic-related fraud, pharmacists should caution patients regarding the limitations of unapproved pharmacogenetic tests and advise them to not alter their medication regimen without first consulting their health care provider. Furthermore, pharmacists should counsel patients to be wary of individuals other than their regular health care providers offering pharmacogenetic tests, even if these individuals seem to represent a legitimate company advertising its services at a community health fair or senior center.

At the grassroots level, patients can protect themselves from identity theft and unauthorized medical services by reviewing their claim statements for any suspicious service s , and contacting their provider about any questionable items. After contacting the provider, beneficiaries can report suspected fraud by contacting either CMS at or OIG at Medicare and Medicaid fraud is a far-reaching issue that affects both patients and providers.

Beneficiaries must be wary of identity theft and unauthorized medical services reimbursed through Medicare or Medicaid. Likewise, providers and pharmacists must be aware of the regulations surrounding false claims, kickbacks, and referrals because fraud can occur, whether it is intentional or unintentional. By being vigilant around these issues, particularly current trends surrounding opioid and pharmacogenetic-related fraud, pharmacists can safeguard the well-being of their patients as well as the security of their practice.

Salisa C. Disclosure: The authors declare no relevant conflicts of interest or financial relationships. J Am Pharm Assoc Published online Jun Author information Article notes Copyright and License information Disclaimer. Received Mar 9; Accepted May Published by Elsevier Inc.

All rights reserved. Elsevier hereby grants permission to make all its COVIDrelated research that is available on the COVID resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. Abstract Fraud is defined as knowingly submitting, or causing to be submitted, false claims or making misrepresentations of a fact to obtain a federal health care payment for which no entitlement would otherwise exist.

Key Points. Medicare and Medicaid fraud is not uncommon. This paper describes the types and trends of Medicare and Medicaid fraud that are committed and provide recommendations to protect patients and health care practices. By being vigilant around current trends surrounding opioid and pharmacogenetic-related fraud, pharmacists can safeguard the well-being of their patients as well as the security of their practice.

Types of fraud There is no standard in how fraud is classified. Type of fraud Provider examples Beneficiary examples Billing for services or items not provided, or double billing when not required for the patient Provider deliberately claiming the bill for services or items not provided; billing multiple times for the same services or items; or billing deliberately for unnecessary services or items.

Unbundling Billing for multiple codes by creating separate claims for services and supplies that should be grouped together.

Improper coding and upcoding Billing for services and procedures more expensive than provided to patients to increase earnings. Identity fraud or card sharing Intentionally claiming reimbursement for treating a person other than the eligible beneficiary, e. Collusion Provider filing false claims in collaboration with beneficiaries such as patients, pharmaceutical companies, or diagnostic firms for reimbursement.

Supporting providers to file false claims for unnecessary tests and services. Drug diversion Prescribing unnecessary drugs or altering prescriptions for personal use or to resell them. Altering prescription or going to multiple prescribers to get more drugs for personal use or to resell them. Receiving payment from providers for referring other beneficiaries for medical services. Program eligibility Intentionally billing for an ineligible person.

Open in a separate window. Abbreviation used: ID, identification. Fraud detection There are many comprehensive efforts to detect Medicare fraud. Recommendations Prevention of Medicare and Medicaid fraud can be accomplished through several strategies at policy, practice, and grassroots levels. Conclusion Medicare and Medicaid fraud is a far-reaching issue that affects both patients and providers.

Footnotes Disclosure: The authors declare no relevant conflicts of interest or financial relationships. References 1. Klees B. Bagdoyan S.

Dodaro G. Office of Management and Budget. Requirements for payment integrity improvement. PaymentAccuracy Payment Accuracy dataset. COVID fraud alert. Nicholas L. Association between treatment by fraud and abuse perpetrators and health outcomes among Medicare beneficiaries. Gordon D. Machine learning and the future of Medicare fraud detection [e-pub ahead of print].

J Am Acad Dermatol. Krause J. Kickbacks, self-referrals, and false claims: the hazy boundaries of health-care fraud. ASPE advises on policy development and contributes to policy coordination, legislation development, strategic planning, policy research, evaluation, and economic analysis. ASPA provides centralized leadership and guidance on public affairs for HHS' staff, operating divisions, and regional offices.

CFBNP leads the department's efforts to build and support partnerships with faith-based and neighborhood organizations to better serve individuals, families and communities in need. The Centers for Disease Control and Prevention, part of the Public Health Service, protects the public health of the nation by providing leadership and direction in the prevention and control of diseases and other preventable conditions, and responding to public health emergencies.

The Food and Drug Administration, part of the Public Health Service, ensures that food is safe, pure, and wholesome; human and animal drugs, biological products, and medical devices are safe and effective; and electronic products that emit radiation are safe. The Health Resources and Services Administration, part of the Public Health Service, provides health care to people who are geographically isolated, economically or medically vulnerable.

The Indian Health Service, part of the Public Health Service, provides American Indians and Alaska Natives with comprehensive health services by developing and managing programs to meet their health needs.

The National Institutes of Health, part of the Public Health Service, supports biomedical and behavioral research with the United States and abroad, conducts research in its own laboratories and clinics, trains promising young researchers, and promotes collecting and sharing medical knowledge. OCR ensures that individuals receiving services from HHS-conducted or -funded programs are not subject to unlawful discrimination, that individuals and entities can exercise their conscience rights and religious freedom, and that individuals can access and trust the privacy and security of their health information.

The HHS Office of Global Affairs provides leadership and expertise in global health diplomacy to contribute to a safer, healthier world. OIG protects the integrity of HHS programs as well as the health and welfare of the program participants.

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OGC provides quality representation and legal advice on a wide range of highly visible national issues. ONC provides counsel for the development and implementation of a national health information technology framework. The Substance Abuse and Mental Health Services Administration, part of the Public Health Service, improves access and reduces barriers to high quality, effective programs and services for individuals who suffer from or are at risk for addictive and mental disorders, as well as for their families and communities.

Washington, D. A-Z Index. Health and Human Services Agencies and Offices. Visit ACF website. Visit ACL for more info. Visit ASPR for more info. Visit AHRQ for more info. Visit ASA for more info. Visit ASFR for more info. Visit ASH for more info. Visit ASL for more info. Visit ASPE for more info. Visit ASPA for more info.

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Organization Chart. Why a Career at GAO? Am I Qualified? Company Culture. Reasonable Accommodations. The ACA standardized eligibility to some extent so that more people could qualify. The ACA added funds for the Medicaid Expansion, which also sometimes includes treatment for substance use disorders.

The qualifying income range is percent to percent of the federal poverty line. The Basic Health Plan must offer ten essential benefits and exceed minimum economic value.

The NY and Minnesota basic health plans enrolled nearly , people in The fees were low in contrast to similar plans in the Marketplace. Based on the first annual cycle, the states may find ways to expand this model. The CMS administers the Medicare program. The Medicare programs have both public and private managed care. The programs below are the Major Medicare programs that provide health insurance and medical care for older and disabled Americans. The two parts of the major federal health law for the elderly make a powerful combination.

They provide a fixed fee for service network made up of every hospital and doctor that accept Medicare. There is no gatekeeper physician to track patients care and ration services.

There are no controls over patients, and they can seek advice at any point along the large network of participating medical services providers. It provided hospital care and medical services to participants. The CMS used the bargaining power of its millions of participating members to press low-cost arrangements. The Original Medicare is still the majority choice of new and existing users.

Unlike most managed care, there are no preferences for one set of providers over another. There are no structured impediments to seeking care from specialists. Some services have a low supply, and there have been occasional price barriers.

The Affordable Care Act added prevention and wellness benefits to all qualified health plans. The CMS incorporated these changes into Original Medicare and participants get free screenings, vaccines, and examinations as part of the conversion. These changes increased the value of Original Medicare without increasing the price. Many valuable Medicare services come with copays and Part B cost sharing at a typical rate of 20 percent.

For some fixed income participants, the persistent costs of copays and coinsurance created barriers to getting regular care. The Obamacare changes help them in particular ways; it provides a no-cost way to add some basic healthcare and annual services.

After the passage of Original Medicare, the Congress revisited the subject and decided to add a greater range of consumer choice. They did this by creating marketing corridors for private insurance companies to sell products to Medicare customers.

Medicare Advantage plans must meet the coverage requirements of Original Medicare ; they have a wide range of freedom to devise methods of meeting Original Medicare.

Advantage plans can vary coverage change priorities and create ways of controlling overall costs. They can add no cost and low-cost popular benefits. Some Advantage plans cost less than part B and many subscribers look for low prices.

Advantage plans can combine Part D- Prescription Drug benefits. Prescription benefits stand alone in Part D, in Advantage plans, they offer consumers a one-stop shopping experience for hospital, medical, and prescription drug coverage. The CMS operates a state of the art innovations center that focuses on new techniques in every phase of CMS operations, information management, and program delivery. These innovations run a wide course.

They include a demonstration that involves measuring approaches to patient care, and they reach to the level of managing benefits for classes of Medicare or Medicaid users. CMS is transforming the way that Medicare and Medicaid do business. At the very core of these programs, the driving force has been the volume of work. The programs were categorically judged by the numbers of patients, treatment delivered and so forth.

The change now under CMS management is to value-based assessment. The goal to watch is the number of long-term successful patient outcomes. Collaboration using high technology communications and data sharing is a key to continuing progress. A quiet revolution is taking place in US healthcare led by the CMS in the steps towards value-based care. To the extent that CMS is a purchaser, it can help determine the priorities of the industry. Value-based accounting, purchasing, and systems promise to refocus health care on the importance of good health and good outcomes in medical care.

Better spending can cause better patient health, fewer re-admissions, and a greater number of successful long-term treatments. The CMS instituted a program of bonus payments for prescription drug plan providers.

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