Phantom Billing, Fake Prescriptions, and the High Cost of Medicine

Phantom Billing, Fake Prescriptions, and the High Cost of Medicine

by Terry L. Leap
     
 

ISBN-10: 0801449790

ISBN-13: 9780801449796

Pub. Date: 04/14/2011

Publisher: Cornell University Press

U.S. health care is a $2.5 trillion system that accounts for more than 17 percent of the nation's GDP. It is also highly susceptible to fraud. Estimates vary, but some observers believe that as much as 10 percent of all medical billing involves some type of fraud. In 2009, New York's Medicaid fraud office recovered $283 million and obtained 148 criminal convictions

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Overview

U.S. health care is a $2.5 trillion system that accounts for more than 17 percent of the nation's GDP. It is also highly susceptible to fraud. Estimates vary, but some observers believe that as much as 10 percent of all medical billing involves some type of fraud. In 2009, New York's Medicaid fraud office recovered $283 million and obtained 148 criminal convictions. In July 2010, the U.S. Justice Department charged nearly 100 patients, doctors, and health care executives in five states of bilking the Medicare system out of more than $251 million through false claims for services that were medically unnecessary or never provided. These cases only hint at the scope of the problem.

In Phantom Billing, Fake Prescriptions, and the High Cost of Medicine, Terry L. Leap takes on medical fraud and its economic, psychological, and social costs. Illustrated throughout with dozens of specific and often fascinating cases, this book covers a wide variety of crimes: kickbacks, illicit referrals, overcharging and double billing, upcoding, unbundling, rent-a-patient and pill-mill schemes, insurance scams, short-pilling, off-label marketing of pharmaceuticals, and rebate fraud, as well as criminal acts that enable this fraud (mail and wire fraud, conspiracy, and money laundering).

After assessing the effectiveness of the federal laws designed to fight health care fraud and abuse—the antikickback statute, the Stark Law, the False Claims Act, HIPAA, and the food and drug laws—Leap suggests a number of ways that health care providers, consumers, insurers, and federal and state officials can bring health care fraud and abuse under control, thereby reducing the overall cost of medical care in America.

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Product Details

ISBN-13:
9780801449796
Publisher:
Cornell University Press
Publication date:
04/14/2011
Series:
Culture and Politics of Health Care Work Series
Pages:
256
Product dimensions:
6.40(w) x 9.30(h) x 1.00(d)

Table of Contents

Preface ix

Acknowledgments xi

Introduction: The Big Picture 1

1 Health Care Fraud and Its Facilitating Crimes 21

2 The Major Health Care Fraud Laws 41

3 Fraud in Fee-for-Service and Managed Care: Different Sides of the Same Coin 60

4 Fraud at Major Hospitals: Profits at Any Cost, Part One 97

5 Fraud in the Pharmaceutical, Medical Equipment, and Supply Industries: Profits at Any Cost, Part Two 116

6 Fighting Health Care Fraud and Abuse 144

Conclusion 177

Appendix: A Note on the Major U.S. Public Insurance Programs 183

Notes 189

References 207

Index 231

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