Explore BrainMass

Preventing Fraud and Abuse in Managed Care

I need help composing a 1200-1500 words paper describing research on Preventing Fraud and Abuse in Managed Care. Detail the following:
Define the Challenges and Problems Associated With Preventing Fraud and Abuse in Managed Care
Recommend Solutions
Implementation of Solutions
Summary and Conclusion
Works Cited
Please use quality original material and sources only. Thank you.

Solution Preview

Medicare: Fraud and Abuse Control Pose a Continuing Challenge: HEHS-98-215R. Government Document GAO Reports. 7/15/1998

Preventing fraud and abuse fallout. By: Mayer, C. Michael, hfm (Healthcare Financial Management), 07350732, Apr95, Vol. 49, Issue 4

The role of the states in combating managed care fraud and abuse. Academic Journal By: Krause, Joan H.. Annals of Health Law , 1999, Vol. 8, p179-199, 21p;


To gain a scope of how much money is potentially lost as a result of healthcare fraud; (you) must first understand the amount of money that is spent on healthcare in the United States each year, which in 2011 was $2.27 trillion dollars. America has the highest amount of money spent on healthcare of all other nations in the world, with over four billion health insurance claims processed in the United States in 2011. Therefore, the sheer amount of money that is spent on healthcare as well as the capitalistic market leaves American healthcare open for abuse and fraud. Tens of billions of dollars are lost every year as a result of healthcare fraud and abuse in managed care.


Fraud and abuse in managed care originates from many different forms of fraud that include billing for services in which healthcare providers never rendered, adding additional charges and procedures that didn't take place, healthcare providers deliberately billing Medicare or Medicaid for the most expensive services despite patients not needing these services, which is a practice known in the industry as up-coding, placing patient's health at danger by diagnosing more serious conditions to justify the inflated prices, and provided (which often requires the accompanying "inflation" of the patient's diagnosis code to a more serious condition consistent with the false procedure code). In the most egregious of fraud and abuse cases, healthcare ...

Solution Summary

Preventing Fraud and Abuse in Managed Care