Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

The Government

Who Is the Government?

The prior sections have discussed the government roles with respect to being a plan sponsor for programs, such as Medicaid and Medicare. The other major market presence involves ongoing legislative changes and the monitoring of those changes to balance the inequities in the marketplace.

What Are Some Examples of Government Fraud?

Fraud schemes can involve acts committed by government-contracted vendors. Internal issues tend to materialize from a contracting perspective with a particular vendor. If you review the history of indictments of government vendors, you will find examples of TPAs misrepresenting performance guarantees, mishandling claims, and mishandling beneficiary information. The next layer of fraud schemes is the submission of false claims for reimbursement, which can be perpetuated by any player in the P-HCC.

OC is a growing issue and concern. One example is the case in which the perpetrator did not even set foot on U.S. soil. A Russian obtained the Social Security numbers of a group of deceased Russian American immigrants. He submitted false claims, set up post office boxes in the United States, hired runners to collect the checks mailed to these boxes, and cashed in. With respect to false claims activities, OC fraud schemes are similar to those experienced by private insurers and are noted under provider fraud scenarios.

Participating in a government program forms a contractual relationship between the parties. The rule governing ...