Ethical Dilema Essay

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July 30, 1965, President Johnson signed into law Medicare and Medicaid. The unique payment methods created and used by these two programs have led to several cases of healthcare fraud, more often involving Medicare. Medicare fraud can fall into three categories: phantom billing, patient billing, up coding or unbundling schemes (CMS). Phantom billing is when a medical provider bills Medicare for procedures that were never perform or were completely unnecessary. When a Medicare beneficiary exchanges their Medicare number and says they received services they actually did not receive in exchange for kickbacks is an example of patient billing. Finally, upcoding is when providers inflate patient’s bills and improperly code the procedures to make it seem that the patient was sicker than they actually were. The following paragraphs will discuss a recent example of Medicare fraud, methods the Center for Medicare and Medicaid Service are implementing in order to prevent future fraud cases, organizational policies that can prevent individuals from committing or falling victim to fraud, and recommendations to prevent future incidents of Medicare fraud. February 28, 2012, Dr. Jacques Roy and six others from North Texas were indicted in the largest healthcare fraud case in U.S. history (CBS DFW). Dr. Roy and the others have been accused of cheating almost $380 million from Medicare and Medicaid between January 2006 and November 2011 (CBS DFW). He owned and operated Medistat Group Associates, an association of healthcare providers that provided home health certifications and performed home visits. Home health certifications are needed prior to Medicare paying for these services. According to court documents, between January 2006 and November 2011, Medistat certified, “more than 11,000 Medicare beneficiaries for home health services and had more patients than any other

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