Forensics Journal - Stevenson University 2015

FORENSICS JOURNAL providers and facilities desiring operational identification numbers and legitimacy needed to bill services to the programs. The NSC collects data from application forms and uses it to perform various types of information verification for individuals or entities seeking provider status (Rozovsky, 1998, p. 211). The process is generally administrative and while it does utilize databases to corroborate provided documentation, a more investigative approach would yield more refined and verifiable results. Checks spanning financial, judicial, licensure, partnership, educational and residential levels would expose any existing areas susceptible or potentially susceptible to fraud, waste or abuse. Full business, billing and payment plans and models as well as planned internal controls submitted by the potential provider could reveal essential administrative flaws or weaknesses that could attract fraudulent or wasteful billing of the programs. Since their inception, the Medicaid and Medicare programs have been susceptible to cyclical and systematic fraud, waste and abuse due in large part to policy and regulation weaknesses, gaps, ambiguity and lack of transparency. Some of the very issues the programs were created to address are the reasons program costs and the exorbitant waste of remunerate funding continue to expand and over-burden Federal and state treasuries, budgets and taxpayer responsibilities. While current program integrity efforts work to reactively police the inadvertent and purposeful deficiencies and exploitations of the publicly-funded healthcare system, new proactive and unified approaches are needed to end the consistent leaching of taxpayer monies intended for the healthcare necessities of aged, disabled and disadvantaged citizens. Transparency, committed amalgamation of resources, and state and Federal dedication to policy and regulation clarity and consistency will enable the Medicaid and Medicare programs to successfully fulfill the needs for which they were originally created long into the future. In recognition of prior industry weaknesses, a main focus of the AHA of 2010 was increased transparency and accountability among providers and payers, while pre-existing public healthcare entities such as the Medicaid and Medicare programs could greatly benefit from similar updates (Cimasi, 2014, p. 664). Within the past decade, hospitals and other healthcare facilities have adapted similar transparency efforts in response to lowered patient satisfaction reports. By updating business models to allow readily available and easy to understand dissemination of accurate and up-to-date wait and referral times, care costs, available services, and concise and time-effective care plans, these facilities reported improved patient satisfaction equating to not only higher revenue, but larger profits sustained over time (M. Stevens, 2007, p. 5). Utilizing a similar transparency strategy with the publicly-funded sector of Medicaid and Medicare services and provider membership would not only help protect against fraud but would strengthen beneficiary care and the healthcare industry as a whole. REFERENCES Beik, J. I. (2011). Health insurance today: A practical approach (3d ed.). St. Louis, MO: Elsevier/Saunders. Berwick, D., & Hackbarth, A. D. (2012). Eliminating waste in US health care. Retrieved September 25, 2014, from http://www.jama.jamanetwork.com Bowers, N. (2014, September 3). Medicaid provider convicted of fraud. Retrieved October 1, 2014, from http://www.8newsnow.com Bowman, A. O., & Kearney, R. C. (1990). State and local government. Boston, MA: Houghton Mifflin. Chaikind, H. R. (2004). The Health Insurance Portability and Accountability Act (HIPAA): Overview and Analyses (3d ed.). New York, NY: Novinka. While raising the standard for participating providers and increasing program transparency, a rigorous pursuit of ongoing Medicaid and Medicare fraud, waste and abuse should engage simultaneously on the largest and most public scale seen by the programs to date. Although HHS, OIG, DOJ and CMS do collaborate to exchange information and resources pertinent to program integrity, a partnership bolstered by additional funding and reenergized by open and purposeful communication between entities would send a very powerful message of zero tolerance. Ongoing audit and recovery efforts would be strengthened and expedited and the recouped expenditures would be reinvested into the expanded detection effort at a faster and larger rate. State legislature and Medicaid and Medicare programs would also play a vital role in working to prevent future expenditure exploitation by making commitments to solidify the areas of program policy that are weak or susceptible to fraud and/or unclear or contradictory regarding policy and regulation expectations. Cimasi, R. J. (2014). Healthcare valuation: The financial appraisal of enterprises, assets, and services. Hoboken, NJ: Wiley. City News Service. (2014, September 19). Hawthorne woman found guilty in $7 million medicare billing scheme. Retrieved October 1, 2014, from http://www.socalnews.com/contact.html Davis, B. H. (n.d.). Improper payments: Government-wide estimates and reduction strategies. Retrieved September 30, 2014, from http://www.irs.gov/uac/Static/Testimony-before-the-House Executive office of the president: Analytical perspectives fiscal year 2015 budget of the U.S. (2014). Claitors. 71

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