Healthcare Fraud

Government Healthcare Programs

Capitol

Medicare is by far the most massive government healthcare program, accounting for 15% of total federal spending to provide healthcare and financial security to all individuals aged 65 and over, as well as those with a long-term disability and those with End-Stage Renal Disease. While this is the largest program (and thus the greatest opportunity for fraudulent claims), there are several other government healthcare programs that help pay for many medical care services, including hospitalizations, doctor visits, prescriptions, prevention services, skilled nursing facilities, home health and hospice care.

These are the six federal health care programs where fraudulent billing occurs:

  • Medicare – The largest federal and state healthcare program provides healthcare insurance to all individuals over 65 years and those with a long term disability or End-Stage Renal Disease. Insurance is offered under Part A (Hospital: covering hospital stays, skilled care, hospice and some home health care), Part B (Medical: covering doctor services, outpatient care, supplies and prevention) and Part D (Prescription drug coverage). Part C – Medicare Advantage – uses managed care organizations to oversee its offering of healthcare coverage.
  • Medicaid – A federal and state health insurance program, operated by managed care organizations, for low-income Americans and their children, and people with certain disabilities.
  • The Children’s Health Insurance Program (CHIP) – A federal program funding healthcare for children in low-income families.
  • TRICARE – Administered by the Department of Defense, this program provides healthcare coverage for members of the military and their families.
  • Veteran’s Health Administration (VHA) – This program operates hospitals and clinics across the country and provides healthcare services to military veterans.
  • The Indian Health Service – The federal agency responsible for providing healthcare to American Indians and Alaskan Natives.

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