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CHEP 2
Chantell Copeland
Chapters Included: 13 & 14
Healthcare Fraud
Santa Fe College

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America is a democratic country where the system cannot truly control that the rich are too rich
and the poor are too poor. IRS and credit card fraud are popular ways that the poor use to get rich
fast. Although illegal, access to how to commit fraud is at arms length for a lot of Americans.
IRS and credit card fraud are generally the first types of fraud that come to mind when people
think of fraud; however, healthcare fraud is at an all time high. The government has to use
billions of dollars to provide the Medicaid and Medicare programs to citizens, as well as using
billions of dollars to protect it from fraudulent activity. The purpose of this paper is to emphasize
the amount of Medicare, Medicaid and insurance health care fraud taking place in America and
possible solutions.
Health care fraud remains an enormous problem within the United States. In the last 25
years, health care fraud has been identified as the number two crime problem in America after
violent crime. Although the social and political landscape of this nation has changed over the the
years, health care fraud remains a top priority because of the large impact that it has on the nation
and its tax payers. The National Health Care Anti-Fraud Association, a nonprofit collaboration of
federal and private health care fraud special investigative units, estimates that between 3% and
10% of health care expenditures are lost to fraud, which equates to approximately $78 to $260
billion stolen from taxpayers on an annual basis (Dietz, Gamble, Marchlowska & Wheeler,
2013). These findings imply that the problem is not with taxes, the government or the programs
themselves; but with regulating fraud.
As stated above, our country has a huge balance problem. Many people that partake in
illegal activities including insurance fraud would argue they have to take what is rightfully
theres. Minorities are more likely than whites to face access to healthcare problems (Shi &Singh,
2013, pg. 327, ). NBC news reportedly discovered several businesses in Miami, FL owned by

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minorities that were not legitimate at all. They interviewed an Hispanic male, that largely
partook in Medicare and Medicaid fraud and stated The theft is so wide spread and easy that for
every crooked company shut down, ten more spring up (NBC news, 2007). The fact that people
believe and actively commit this crime as easily makes me question the amount of protection we
really have against fraud. According to the video, this man was able to steal billions of dollars in
as short of a time as a month. The healthcare scam is quick and easy and I believe that had he
and his business stayed under a smaller radar, the scam could have continued a lot longer.
Minorities are not the only ones cashing in on the easy access to healthcare fraud. Doctors of
private practices are committing fraud on the grounds that majority of the insurance companies
dont pay out enough money, especially Medicaid and Medicare. the New York times reported
homeless people being recruited and whoever had a valid Medicaid card would be packed into a
van and sent to medical clinics around New York City. After spending hours at the clinic
partaking in unnecessary tests and fake diagnoses, the homeless people would be sent off with
sneakers selected from stacks of shoeboxes in the clinics basements. The doctors, staff
members and billing specialists, meanwhile, would rack up hundreds or thousands of dollars per
recruit in false Medicaid claims, prosecutors said. The above example has provided proof of the
major holes that our system has indicating an overall inadequacy in protection of the integrity of
the government provided healthcare issues.
Health care spending is expected to grow. Under the Affordable Care Act expansion of
Medicaid by liberalizing the eligibility criteria is expected to increase Medicaid enrollment by
19.5 million people and spending is projected to grow 20.3% (Shi & Singh 2013, pg. 339). With
this amount of spending expansion, only in regards to Medicaid, the estimated increase on fraud
can be projected, in my opinion, to double as well. With this being said, I believe that the

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government needs to establish more rules, laws and boundaries on how easy it is to open a
practice, a medical supply business or any business that can potentially rob the government and
its people of billions of dollars.
From my experience I have encountered many people that have lied on government
funding applications in order to get assistance such as Food Stamps, WIC or Section 8 housing.
People have even been dishonest on their Medicaid applications in order to receive free
insurance benefits. I have even heard statements such as I can lie on the application because Im
paying for it anyway since I pay taxes. This mindset and the fact that there are so many
loopholes in our system is why the honest people that sincerely work hard, yet are genuinely in
need suffer. I would consider the verification process a joke seeing how many people that arent
truly eligible for assistance slip through the cracks. A business was able to accrue over a billion
dollars in just one month by submitting false claims. This shows that red flags don't pop up until
people have almost gotten away with it. I believe that the elimination process can be more indepth and that more investigation should take place prior to approval before any fraud can take
place. Overall healthcare fraud has an huge impact on the economy and the tax paying citizens.
In my opinion, it is not just about passing the law to help people in need, it is also about
protecting the people that are helping the people in need in order for a overall more efficient
system.

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References
NBC News. (2007). A clip from NBC news. Retrieved from
https://www.youtube.com/watch?v=I3ooR8aU_Ww
Clifford,S. (March 31,2015). 9 NewYork doctors are accused of defrauding medicaid with homeless
people. The NewYork Times.
Retrieved from
http://www.nytimes.com/2015/04/01/nyregion/9newyorkdoctorsindictedinmedicaidfraudusinh
omeless-patients.html?_r=0
Shi, L. & Singh, D., (2013). Essentials of the U.S. health care system. (3 ed.). Burlington, MA: Jones
& Bartlett Learning