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

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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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Editorial Reviews

From the Publisher

"Concerning health care fraud and abuse, Terry L. Leap thoroughly describes the sources and magnitude of the problem, which may approximate $300 billion annually in the United States. Given the government's growing appetite for revenue, all health care providers are urged to read this book and implement its recommendations before being snared by the government."—Michael J. Stahl, William B. Stokely Professor of Business and Director of the Physician Executive MBA Program, University of Tennessee

"One doesn't often find superb investigative reporting in the academy or from a university press. Terry L. Leap provides a remarkable exception in his devastating account of rampant fraud in the American healthcare system. One can only hope that every legislator, Medicare administrator, and health executive in the country will read and heed this well-documented, clearly written report."—Mark Dowie, Host and Executive Producer, Talking Point Radio

Library Journal
Often lost in the cacophony of the ongoing debate over what to do about health care in this country is the broad consensus that fraud is one of the major drivers of increasing costs and substandard care. Leap (management, Clemson Univ.; Dishonest Dollars: The Dynamics of White-Collar Crime) offers detailed descriptions of the players and of existing laws along with definitions of the various types of fraud and how they permeate every aspect of health care. No system, public or private, domestic or worldwide, is immune. He shows the pervasiveness of a problem that affects and is enabled by everyone from consumers to providers to private and government insurers, to educators, legislators, and manufacturers. To combat the problem, he recommends serious educational efforts to help consumers become the first line of defense and going after and incarcerating individuals rather than chasing organizations and companies, which can easily absorb even large fines. VERDICT This is a thorough, well documented but dry account, interspersed with relevant anecdotes. Those with a strong interest in the details of the complex health-care dilemma will find it useful.—Dick Maxwell, Porter Adventist Hosp. Lib., Denver
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Product Details

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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