Managed Care Medicare and Medicaid fraud have become pervasive in the United States, costing taxpayers billions of dollars annually. One form of healthcare fraud that has been on the rise is Risk Adjustment Factor (RAF) score fraud. RAF score fraud occurs when healthcare providers, managed care organizations, or insurers manipulate patient data to increase RAF …
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The Benefits of Being the First to File a Whistleblower Claim in Exposing Healthcare Fraud
Whistleblowing to expose healthcare fraud is a courageous act that reveals unlawful practices and protects patients from substandard care. However, to be effective, whistleblowers must follow a specific set of rules in a timely manner, including being the first to file a whistleblower claim. In this article, we define what it means to be “first …
How to Report Nursing Home and Assisted Living Fraud
Medicare fraud within Assisted Living Facilities across the country. As more facilities take advantage of the system, it’s important to know how to spot the various forms of fraud that can occur in these settings. Identifying nursing home and assisted living fraud crucial in ensuring that beneficiaries receive the care they deserve and that taxpayer …
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Top 7 Most Common Medicare/Medicaid Scams by Medical Providers
Medicare is a federal health insurance program that covers eligible individuals who are over 65 years old, disabled, or have end-stage health complications. State or Federal insurance fraud is a type of healthcare fraud that occurs when healthcare providers, managed care organizations (MCOs) or nursing homes file false claims or use deceptive practices to receive …
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Billing and Upcoding: How Physicians Can Stand Up to Managed Care Organizations
As healthcare costs continue to rise, government programs such as Medicare and Medicaid, as well as private insurers, rely heavily on managed care organizations (MCOs) to manage patient care and keep costs under control. However, some MCOs engage in fraudulent practices such as medical billing fraud, which includes double billing and upcoding. These practices can …
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Typical Types of Fraud in Long Term Care Facilities and How to Report Them and Potentially Earn a Reward
Fraud within Long-Term Care and Assisted Living Facilities is a serious issue. It’s important to be aware of the various forms of fraud that can occur in these settings in order to protect residents, their families, and the taxpayers funding Medicare programs. Through education and awareness, you can help prevent long-term care fraud and ensure …
How Healthcare Fraud Impacts Vulnerable Populations
It’s easy to see how healthcare fraud can cost taxpayers and governments billions of dollars every year. And while that is not something to be ignored, healthcare fraud also significantly impacts vulnerable populations like the elderly, those with severe illnesses and disabilities, and those on fixed incomes. When organizations take advantage of these individuals to …
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Top Managed Care Fraud Trends to Look For in 2023
According to the National Library of Medicine, managed care refers to a healthcare insurance approach that integrates the financing of care and related services to keep the costs to the purchaser at a minimum while delivering what is appropriate for beneficiaries. The government has designed this delivery system to organize and manage healthcare between Medicaid …
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What Does Medical Loss Ratio Fraud Look Like in Managed Care
Medical Loss Ratio (MLR) fraud occurs when plans knowingly misrepresent a proportion of funds spent on patient care and quality improvement measures as opposed to administrative expenses and profits. In this article, we take a deeper dive into MLR fraud and how it impacts our healthcare system. What is Medical Loss Ratio? The Affordable Care …
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Managed Care: Exposing Medicare Advantage Fraud and Abuse
Medicare Advantage is a type of health insurance plan offered by private companies contracted by the government. Also known as Medicare Part C, Medicare Advantage was designed to incentivize health insurers to develop innovative ways to improve care while decreasing costs. However, a report by the New York Times shows many of the large insurers …
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