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 …
Continue reading “Top Managed Care Fraud Trends to Look For in 2023”
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 …
Continue reading “What Does Medical Loss Ratio Fraud Look Like in Managed Care”
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 …
Continue reading “Managed Care: Exposing Medicare Advantage Fraud and Abuse”
Illegal kickbacks in managed care insurance are costly schemes that corrupt the healthcare system. When dishonest managed care organizations (MCOs) devise unlawful kickback schemes to defraud government healthcare programs, physicians base their decisions on financial gain rather than the medical needs of their patients. It’s a dangerous crime that undermines the ethics of our medical …
Continue reading “Managed Care Insurance Fraud: Medicare and Medicaid Kickbacks”
Managed care insurance fraud is an unfortunate reality that affects taxpayers, the government, and the millions of individuals enrolled in government-funded health plans. It’s a costly crime that steals at least $308.6 billion from American consumers every year. We must all work together to put a stop to schemes like upcoding and phantom billing by …
Managed care is a form of health insurance that aims to reduce costs and improve quality of care by leveraging contracts with care providers and medical facilities to increase efficiency of coordinated patient care. Within the system, federal and state governments contract private insurers, also known as Managed Care Organizations (MCO), to provide health insurance …
Continue reading “The Impact of Risk Adjustment Fraud in Managed Care Insurance”
Fraud in managed care is an unfortunate reality that costs the government and taxpayers billions of dollars each year. Schemes like falsifying patient records, upcoding, cherrypicking, and enrollment fraud siphon money away from the 160 million Americans enrolled in legitimate government healthcare programs, increase taxes, and contribute to rising healthcare costs. This is why it’s …
Unfortunately, Medicare, Medicaid, and other government healthcare programs are impacted by fraud. However, we’ve seen a number of successful managed care fraud cases resulting in settlements and whistleblower rewards over the last few years. In managed care, federal and state governments contract private insurers, also known as Managed Care Organizations (MCO), to provide health insurance …
Continue reading “Managed Care: 3 Successful Fraud Cases and Awards”
Managed care fraud is an unfortunate reality that costs the government and taxpayers billions of dollars each year. Managed Care Organizations (MCO) involved in managed care fraud game the system by falsifying patient records and miscoding patient diagnoses in order to qualify for additional funds. This type of fraud takes money away from legitimate government …
Continue reading “Managed Care Fraud: Schemes That Can Lead to FCA Liability”
In July 2022, the Department of Justice (DOJ) announced criminal charges against 36 defendants for committing a variety of alleged schemes to defraud Medicare using telehealth. According to the DOJ, the alleged actions of the defendants led to $1.2 billion in medical fraud, with much of that coming from fraudulent telehealth claims for cardiovascular and …
Continue reading “Rise of Telehealth Fraud in the Healthcare Industry”
