Does Medicare cover racial and ethnic disparities in health care?
Racial, Ethnic, and Gender Disparities in Health Care in Medicare Advantage, April 2020 April 2020 Racial, Ethnic, and Gender Disparities in Health Care in Medicare Advantage
What is The racial makeup of Medicare beneficiaries in Massachusetts?
In 2018, an estimated 69.3 percent of all MA beneficiaries were White (versus 75.5 percent of the general Medicare population 6
Which racial groups have higher levels of medication use?
o Asians or Pacific Islanders, Blacks, and Hispanics were more likely than Whites to have had at least one appropriate follow-up visit during the year to monitor their use of a higher-risk medication. The difference between each of these groups and Whites was less than 3 percentage points.
Which groups receive better health care?
• Better = Population received better care than Whites. Differences are statistically significant (p < 0.05), are equal to or larger than 3 points on a 0–100 scale, and favor the racial or ethnic minority group.
Who typically commits health care fraud?
Health care fraud can be committed by medical providers, patients, and others who intentionally deceive the health care system to receive unlawful benefits or payments. The FBI is the primary agency for investigating health care fraud, for both federal and private insurance programs.
What is the most common Medicare fraud?
The following are the most common areas of healthcare fraud of which you should be aware:#5 – Kickback Schemes. ... #4 – Medically Unnecessary Services. ... #3 – Failure to Properly Charge Medicare and Medicaid Patients for Prescriptions. ... #2 – Allowing Nurses and Staff to Perform Examinations. ... #1 – Upcoding.More items...•
Which is the most common form of health care fraud and abuse quizlet?
Billing for services never rendered is one of the most common types of healthcare fraud. You just studied 25 terms!
What percent of healthcare is fraud?
3 percentThe National Heath Care Anti-Fraud Association estimates conservatively that health care fraud costs the nation about $68 billion annually — about 3 percent of the nation's $2.26 trillion in health care spending. Other estimates range as high as 10 percent of annual health care expenditure, or $230 billion.
What factors might be red flags for Medicare fraud?
Some red flags to watch out for include providers that:Offer services “for free” in exchange for your Medicare card number or offer “free” consultations for Medicare patients.Pressure you into buying higher-priced services.Charge Medicare for services or equipment you have not received or aren't entitled to.More items...
What is a major part of Medicare fraud?
Billing for physician visits and services not rendered or not medically necessary. Billing for durable medical equipment such as wheelchairs, body jackets, incontinence supplies or diabetic supplies without a doctor's prescription.
Which of the following is an example of a common form of healthcare fraud and abuse quizlet?
In Medicare, the most common forms of fraud and abuse include billing for services not furnished; misrepresenting the diagnosis to justify payment; soliciting, offering, or receiving a kickback; unbundling; falsifying certificates of medical necessity; and billing for a service not furnished as billed, known us ...
What does OIG mean in medical terms?
The Office of Inspector GeneralOIG stands for The Office of Inspector General, which is part of the U.S. Department of Health and Human Services (HHS).
What forms of fraud and abuse may be present in a healthcare setting quizlet?
Terms in this set (8) What forms of fraud and abuse may be present in a health-care setting? Forms may include the areas of false claims and billing practices, and the use of kickback schemes.
What is the largest area of fraud identified by the insurance industry?
What is the largest area of fraud identified by the insurance industry? A: Medicare fraud is the most costly type of insurance fraud in the US. In 2017, it cost taxpayers $60 billion.
How common is healthcare fraud in the United States?
(July 2021) In fiscal year 2020, there were 330 health care fraud offenders, who accounted for 7.7% of all theft, property destruction, and fraud offenses. The number of health care fraud offenders decreased by 36.2% since fiscal year 2016. The USSC HelpLine assists practitioners in applying the guidelines.
How common is fraud and abuse in healthcare?
Fraud and abuse, widespread in both the public and private health care sectors, account for 3 percent to 10 percent of Medicaid payments nationwide. Among 28 federal programs examined by the U.S. General Accountability Office in 2007, Medicaid had the highest number of improper payments.
What is a free consultation?
A provider offers “free” consultations for Medicare patients, then uses their private information to bill Medicare. Offering free medical equipment or devices in exchange for a patient’s Medicare number. Offering gifts to incentivize potential Medicare patients to use a provider’s services.
What is Medicare billing?
In essence, Medicare is being billed for services that were not rendered. Patient Billing. Similar to the phantom billing, patient billing occurs when the patient is helping out the medical provider by giving them their Medicare number.
What is Phantom Billing?
Phantom billing is when the medical provider bills Medicare for “phantom” medical procedures or items. In other words, the provider bills the program for medical procedures that never were performed, for medical tests never completed, for unneeded medical equipment or devices, or for equipment that is billed as new when it is actually used.
How much money did Armenian gangsters make in Medicare fraud?
In 2010, a group of Armenian gangsters committed a massive Medicare fraud scheme that created $160 million in fake billings. They created 118 “phantom” clinics that used the stolen identities of doctors and patients to create fake billings to Medicare. The case included over 70 defendants in on the scheme.
What is Medicare fraud?
Medicare fraud, at its most basic, is the attempt to receive monetary reimbursement from the Medicare program that the patient is not legally entitled to. There are a few different ways that Medicare fraud is enacted. Usually, Medicare fraud involves either doctors or beneficiaries attempting to receive excess or undeserved payment from the program.
How many people are covered by Medicare?
Medicare is the American national health insurance program that provides insurance to the elderly population and occasionally younger people with disabilities. It is administered by the Centers for Medicare and Medicaid Services according to the determinations of the Social Security Administration. There are currently about 60 million people in the United States that receive Medicare. Generally speaking, Medicare often covers up to 50% of the patient’s healthcare costs. The remainder of the costs are often covered by optional private insurance.
What is the most profitable healthcare crime in the US?
Medicare Fraud: The Most Profitable Healthcare Crime in the US. July 22, 2021. January 10, 2020. The healthcare system in the United States is pretty complicated, no doubt about it. And with such a complicated system, there are always people trying to find ways around high medical costs. Medicare fraud is one of those ways ...
What is the purpose of the KFF chart?
This chart collection draws on primary and secondary data analyses by KFF and other sources to examine the characteristics, experiences, and outcomes of the Medicare population by race and ethnicity (see Methods for details on data and analysis). It includes data from a variety of sources to describe demographics, health status and disease prevalence, health coverage, access to care and service utilization, and health outcomes, including the most current data available pertaining to disparities related to COVID-19 within the Medicare population. It also documents disparities in income and wealth among people on Medicare.
Do black people get Medicare?
While the vast majority of Medicare beneficiaries across all racial and ethnic groups have some source of supplemental coverage to help fill in Medicare’s benefit gaps and cost- sharing requirements, the share of beneficiaries with different types of coverage varies by race and ethnicity. A smaller share of Black and Hispanic Medicare beneficiaries than White beneficiaries have private supplemental coverage through Medigap or retiree health plans, while a larger share have wrap-around coverage under Medicaid; a larger share of Black and Hispanic than White beneficiaries are enrolled in Medicare Advantage plans
Do people of color have more hospital visits than white people?
Among Medicare beneficiaries, people of color are more likely to report being in relatively poor health, have higher prevalence rates of some chronic conditions, such as hypertension and diabetes than White beneficiaries; they are also less likely to have one or more doctor visit, but have higher rates of hospital admissions and emergency department visits than White beneficiaries.
Why is reducing racial disparities important?
Reducing Racial and Ethnic Health Care Disparities Is Essential for Better Health Care Outcomes and for Lowering Health Care Costs
How much would Medicare save if health disparities were eliminated?
[4] In a report issued in September, 2009, the Urban Institute calculated that the Medicare program would save $15.6 billion per year if health disparities were eliminated. The study examined a select set of preventable diseases among the Latino and African American communities, including diabetes, hypertension and stroke, and concluded that – if the prevalence of such diseases in the African American and Latino communities were reduced to the same prevalence as those diseases occur in the non-Latino white population – $23.9 billion in health care costs would be saved in 2009 alone. [5]
What is the CDC's website for nutrition?
If you live in a food desert, the CDC provides helpful information concerning nutrition so that a buyer can make the best out of a trip to a distant grocery store: http://www.cdc.gov/nutrition/everyone/index.html (site visited June 16, 2015).
What is it called when people have poor access to fresh food?
Areas where people have poor access to fresh and healthy food are sometimes known as "food deserts .". People who live in food deserts are aware of their lack of accessibility to fresh fruits and vegetables and indicate in surveys a desire to have good access to fresh produce.
What are food deserts?
[30] Residents of these neighborhoods must rely on small grocery stores or convenience stores, which carry few – if any – fresh fruits and vegetables. Areas where people have poor access to fresh and healthy food are sometimes known as "food deserts." People who live in food deserts are aware of their lack of accessibility to fresh fruits and vegetables and indicate in surveys a desire to have good access to fresh produce. Thus, unhealthy eating is often the result of structural inadequacies in accessing healthy foods and not necessarily limited to personal dietary choices. [31]
What is the National Hispanic Medical Association?
The National Hispanic Medical Association (NHMA) provides resources to advocates and providers in order to strengthen health care delivery to Hispanic communities. Here is a link for providers: http://www.nhmamd.org/index.php/resources-for-physicians (site visited June 10, 2015).
How can small scales help?
Small scales measures designed to improve access to healthy foods can help change dietary habits. The resulting change in diet for residents of former food deserts leads to better health outcomes and contributes to eliminating ethnic and racial health disparities.
What is CAHPS survey?
Medicare CAHPS surveys are mail surveys-ups baed with on atelephone stratified follow random sample of Medicare contracts beneficiaries, serving with as strata for Medicare Advantage (MA) beneficiaries-for-service and for beneficiaries (FFS) fee enrolled in prescription drug plans (PDPs) and states serving as strata for FFS. beneficiariesThe 2017 survey attempted not enrolled to cont in act PDP 844,320 Medicare beneficiaries and340,645, received a 40 percent responses responate. The from 2017 surveysrepresent MA all beneficiaries FFS beneficiaries, 447 MA contracts from that either were required to report (minimum of 600 eligible–599 enrollees), enrollees) and or reported voluntarily (450PDP beneficiaries 55 PDP contract froms with at,500 least eligible 1 enrollees. The data presented in this report pertain only to MA beneficiaries.
What is CAHPS report?
The report is based on an analysis of two sources of information. The first source is the Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey, which is conducted annually by the Centers for Medicare & Medicaid Services (CMS) and focuses on experiences with the health and drug plans (e.g., ease of getting needed care, how well providers communicate, and getting needed prescription drugs) of Medicare beneficiaries across the nation. The second source of information is the Healthcare Effectiveness Data and Information Set (HEDIS). HEDIS collects information from medical records and administrative data on the technical quality of care that Medicare beneficiaries receive for a variety of medical issues, including diabetes, cardiovascular disease, and chronic lung disease. A comprehensive list of measures included in this report appears on p. viii. Scores on CAHPS measures are case-mix adjusted, as described in the appendix. HEDIS measures are not case- mix adjusted.
How is HEDIS data stratified?
For reporting HEDIS data stratified by race and ethnicity, racial and ethnic group membership is estimated using a methodology that combines information from CMS administrative data, surname, and residential location. Estimates of membership in the AI/AN group are less accurate than for other racial and ethnic groups; thus, this report does not show scores for AI/AN beneficiaries on the clinical care measures.
Which group received worse care than Whites?
Racial and ethnic disparities were more variable for the clinical care measures than for the patient experience measures (see figure on p. x). API beneficiar ies received worse clinical care than Whites for 3 measures but received care of similar quality for 16 measures and better quality for 14 measures. Black beneficiaries received worse clinical care than Whites for 14 measures but received care of similar quality for 16 measures and better quality for 3 measures. Hispanic beneficiaries received worse clinical
What does AI/AN mean?
NOTES: AI/AN = American Indian or Alaska Native. API = Asian or Pacific Islander. Racial groups such as Blacks and Whites are non-Hispanic. Hispanic ethnicity includes all races.
Which group was more likely to have had at least one follow up visit during the year to monitor their use of a?
Asians or Pacific Islanders, Blacks, and Hispanics were more likely than Whites to have had at least one appropriate follow-up visit during the year to monitor their use of a higher-risk medication. The difference between each of these groups and Whites was less than 3 percentage points.
What is section 2 of the report?
Section II of the report beginswith a pair of stacked bar charts that show the number of patient experience measures7) and the (out number of of clinical29) for care which measures women (out of received care that was worse than, similar to, or better than the care received by men. Gender data for
What are some examples of Medicare fraud?
Some of the More Common Examples of Medicare or Medicaid Fraud include the following: Paying “kickbacks” in exchange for referring business. “Kickbacks” are customary in healthcare fraud cases. State and federal laws by and large ban payments to individuals who refer patients to a particular hospital or medical provider.
How much money does Medicare pay for healthcare fraud?
Most healthcare fraud today is being committed against Medicare and Medicaid, both funded with U.S tax payer dollars. Medicare pays out over $800 billion a year for claims. Medicaid also has enormous budget, providing $615 billion a year. Their sheer size makes these goliaths a target for those groups committing fraud.
How to avoid inadvertent fraud?
To avoid inadvertent fraud, healthcare providers must maintain accurate billing practices to steer clear of inaccuracies such as overcharges or claims for undocumented or undelivered services. Maintain updated and proper documentation.
What is medical fraud?
Medical fraud is the intentional deception or misrepresentation of healthcare transactions by the provider for the sake of receiving unauthorized benefits or financial gain. Healthcare fraud is committed when a dishonest provider intentionally submits, or causes someone else to submit, false or misleading information for use in determining the amount of healthcare benefits payable by an insurer. Many leading, medical groups calculate fraud to amount up to 10% of all healthcare costs.
What was the role of a family physician in the medical field?
A family physician worked at a medical center where low-income and needy patients were enlisted to submit to needless exams. While he consulted with few patients, medical records were forged by a physician’s assistant to support the billing of Medicaid for medical procedures never performed.
Why did a doctor fabricated his patient's medical records?
He fabricated his patient’s medical records to indicate office visits and treatments that never took place.
Is fraud a premeditated crime?
Even mere allegations of fraud can do considerable damage to the professional reputation of a healthcare practice. Such fraud (or perceived fraud) is not always premeditated. However, it can arise as a result of negligence, sloppiness, mistake or oversight.
Why are civil healthcare programs being fraudulated?
Fraudulent acts are committed against Civil Healthcare programs in order to inflate billing reimbursements and cheat the government. These schemers use a variety of methods to cheat reimbursements and violate the FCA laws for financial gain.
What is FCA claim?
Making an FCA claim provides benefits and protection for whistleblowers who notify the Government first about Medicaid, Medicare or Tricare fraud.
What is Medicare fraud?
Violations of Medicare and Medicaid Laws is fraud. Healthcare fraud against Federal or State programs is a violation of the False Claims Act (FCA).
What is phantom billing?
Phantom Billing is the act of billing for services or treatments not provided to the patient. The most basic and frequent, healthcare providers use this scam to pad their reimbursement reports. A pattern of this conduct is a red flag for investigators, as phantom billing is often accompanied by additional violations.
How is Medicare funded?
Medicare - Medicare is a Federal health care plan funded through payroll taxes for people over the age of 65
What is upcoding in medical?
Upcoding is when a provider bills private insurers or Medicare/Medicaid using a CPT Code for a more expensive treatment than was performed. Two consequences of this are higher insurance costs and inaccurate medical records.
Why do doctors use overtreatment?
Some facilities or doctors use overtreatment in an attempt to avoid liability for malpractice. By ordering ever test coverable under the patient Medicare they claim to have done everything they could.
What is the CAHPS report?
The report is based on an analysis of two sources of information. The first source is the Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey, which is conducted annually by the Centers for Medicare & Medicaid Services (CMS) and focuses on the health care experiences (e.g., ease of getting needed care, how well providers communicate, and getting needed prescription drugs) of Medicare beneficiaries across the nation. The second source of information is the Healthcare Effectiveness Data and Information Set (HEDIS®). HEDIS is composed of information collected from medical records and administrative data on the clinical quality of care that Medicare beneficiaries receive for a variety of medical issues, including diabetes, cardiovascular disease, and chronic lung disease. A comprehensive list of the seven patient experience and 44 clinical care measures included in this report appears on pp. xiv–xv. Scores on CAHPS measures are case-mix adjusted, as described in the appendix. HEDIS measures are not case-mix adjusted.
How is HEDIS data stratified?
For reporting HEDIS data stratified by race and ethnicity, racial and ethnic group membership is estimated using a methodology that combines information from CMS administrative data, surname, and residential location. Estimates of membership in the AI/AN group are less accurate than for other racial and ethnic groups; thus, this report does not show scores for AI/AN beneficiaries on the clinical care measures.
What is the bar on the left?
The bar on the left (patient experience measures) summarizes data from all MA beneficiaries nationwide who participated in the 2018 Medicare CAHPS survey. The bar on the right (clinical care measures) summarizes clinical quality (HEDIS) data collected in 2018 from MA plans nationwide.
Which disparities were more variable for the 44 clinical care measures presented in this report than for the patient experience measures?
Racial and ethnic disparities were more variable for the 44 clinical care measures presented in this report than for the patient experience measures (see Figure 2). API beneficiaries received worse clinical
What are the two clinical care measures?
Two clinical care measures, Breast Cancer Screening and Osteoporosis Management in Women Who Had a Fracture, pertained to women only and so were not eligible for stratified reporting by gender. Two other measures, Statin Use for Cardiovascular Disease and Medication Adherence for Cardiovascular Disease —Statins, were defined differently for men and women and so were also not eligible for stratified reporting by gender.
How long does it take for a black woman to receive telehealth?
Black and Hispanic women who were discharged from an inpatient facility were more likely than White women who were discharged from an inpatient facility to have had an office visit, to have had a home visit, or to have received telehealth services within 30 days of discharge.
What does AI/AN mean?
AI/AN = American Indian or Alaska Native. API = Asian or Pacific Islander. Racial groups such as Blacks and Whites are non-Hispanic. Those who endorsed Hispanic ethnicity were classified as Hispanic regardless of race.