To the chairperson,
New York state Health committee
LOB 823, Albany, NY 12248
Dear Hon. Richard Gottfried,
RE: MEDICAID FRAUD
I am pleased to write to you this day regarding Medicaid. Medicaid is a healthcare program that provides health coverage to needy people in the United States. It has helped adults with low incomes, children, the elderly pregnant mothers and people living with disabilities. Medicaid receives funding from both the federal government and states. Currently, it has over 65 million Americans.
Over the past few years, there have been reported cases of fraud in Medicaid funds. Funds that ought to be used to provide better healthcare services end up being wasted. Bush et al. (2017) reported that there had been an increase in improper payments from 29 billion USD to 36 billion USD in 2015 to 2016 respectively. Improper payments occur when payments are made for services that were not provided. Improper payments and fraudulent activities cost the patients a lot because they become more vulnerable to their conditions. The wastage also costs state governments spending and ruins budget plans. Federal regulations require that individual states Medicaid programs have investigative units as eligibility for the funds. Some states like Arizona have positions for inspectors while others have established integrity divisions. Even though fraud in the context of Medicaid includes activities such as misinterpreting the truth with one’s knowledge in order to benefit from the funds, abuse involve performing an operation that is not in accordance with the medical profession.
I suggest the implementation of a compliance program as a solution to cases of fraud and abuse in Medicaid. An effective compliance program establishes a culture that detects, prevents and resolves conflicts related to violations of the federal and state regulations pertaining to Medicaid and ethical requirements for hospitals. The compliance program may come with various implementations that may help in executing the control measures. There should be well developed expected standards of conduct to promote a compliance culture within hospitals. Adherence to compliance can be included when evaluating staff in order to improve their awareness of the sensitivity of fraud cases. This should be followed by the creation of chief compliance officer position together with other compliance executives who can monitor the program and staff to ensure that compliance standards are adhered to.
Apart from these, educating and training staff may also increase positive outcomes. Although Noe et al. (2017) suggests that too much investment in training and development can be costly to organizations, Laursen (2013) asserts that continuous training and development creates more emphasis on the need for medical staffs to perform their duties without being caught in the web or fraud. The program should have units where reports concerning fraud are received and recorded. The units should be fitted with hotlines where grievances are received. This allows for the establishment of procedures for the protection of anonymity and the retaliation of whistleblowers. Finally, continuous audits can be integrated into the program to allow for easy tracking of compliance. I request that you use the influence of your office to help in the implementation of the compliance program. As discussed above, the program will be highly essential in combating fraud in Medicare. The associated benefits to patients and cost saving are worth the implementation. Thank you so much for taking your precious time in reading.
Bush, J., Sandridge, L., Treadway, C., & Vance, K. (2017). Medicare fraud, waste and abuse. (Doctoral thesis). Marshall University.
Caputo, R. (2008). History of contemporary social policy: Introduction. Journal of sociology & social welfare, 35 (1), 9-16.
Center on Budget and policy priorities (2018). Policy basics: An introduction to TANF. Retrieved from https://www.cbpp.org/research/policy-basics-an-introduction-to-tanf
Heilman, B. (2017). Welfare Reform and Quality of Life: A Systematic Review. Sage
Karger, H. & Stoesz, D. (2018). American social welfare policy: A pluralist approach (8th. ed.). Boston, MA: Pearson.
Laursen, K. K. (2013). Leadership strategies and initiatives for combating medicaid fraud and abuse. (Doctoral thesis). Walden University.
Myles, J. & Quadagno, J. (2001). Political theories of the welfare state. Social Service Review 76, 1.
Noe, R. A., Hollenbeck, J. R., Gerhart, B., & Wright, P. M. (2017). Human resource management: Gaining a competitive advantage. New York, NY: McGraw-Hill Education.