Crackdown on Medicaid Fraud

Medicaid is a federal government program designed to provide health care coverage for low income families and their children, and the disabled. But like any other program, Medicaid is susceptible to fraud and  abuse by others. Each year Medicaid and Medicare are estimated to have $60 billion in fraud a year (Wayne, 2012). This staggering amount is the result of an ongoing issue with the quality and security of the utilization of Medicare/Medicaid. Fortunately, the government has created the Office of Inspector General (OIG) at the Health and Human Services Commission, an organization that is focused on helping to end fraud and recover billions of dollars that Medicaid/Medicare has lost. Although their intentions are necessary, their strategies have brought much opposition from providers and health care organization who provide care for Medicaid patients.

The OIG's strategy consists of an increased reliance on a rule that allows investigators to freeze financing for any health care provider accused of over-billing, more focus on investigations with the biggest potential monetary returns (Ramshaw, 2012). Much of these strategies have been implemented under the new management and leadership of the new inspector general, Douglas Wilson. Along with his deputy, Jack Stick, they have taken a new approach to addressing the problem. According to Wilson, the division had operated like law enforcement, performing lengthy investigations, and instead he wanted to approach the situation as an accountant and freeze the flow of finances to questionable providers (Ramshaw, 2012). Although it is difficult to measure how successful their strategies have been, records show that they have been able to reduce case work from 3 or 4 years to eight weeks.

Where much of the opposition exists is from providers and organizations who treat large numbers of Medicaid patients. Freezing the finances of a health care provider accused of over-billing without a hearing creates huge risks for the organization. Providers who are waiting to get hearings are struggling to to continue providing care, which is resulting in cutting wages, labor hours, and declining Medicaid patients who can not receive care from these places while under investigation.Wilson's response to the frustration of providers is that the O.I.G. gives them the chance to come in for an informal review at any time. If the allegations are unfounded, the unpaid money is reimbursed and their financial flow is restored (Ramshaw, 2012).

Medicare/Medicaid fraud has been going on for too long and it is good to see that someone is willing to be more aggressive and stern in there strategy to resolve this issue. Hopefully, providers who see that it is for the best, that this is not a personal attack on medical practices but to improve the process of providing care for both providers and patients. The success of Wilson and Stick's strategy relies on the cooperation and continuous support of both parties. The billions of dollars that can be saved will benefit everyone and will bring this country closer to having an efficient health care system.  



Ramshaw, E. (2012). The big push on medicaid fraud. The New York Times. Retrieved from:       http://www.nytimes.com/2012/07/20/us/medicaid-fraud-push-gets-results-but-angers-doctors.html?pagewanted=1&ref=health

Wayne, A. (2012). Medicaid fraud audits cost five times amount u.s. found. Bloomberg. Retrieved from: http://www.bloomberg.com/news/2012-06-14/medicaid-fraud-audits-cost-five-times-amount-u-s-found.html