Government Healthcare Programs Susceptible to Fraud

Fraud affects a wide range of healthcare programs funded, directly or indirectly, by the United States and various individual states. As long as the federal government or the government of a state with a False Claims Act pays for some or all of a healthcare program, then fraud against that program may be covered by the Federal or a State False Claims Act.

Some examples of federal and state healthcare programs covered by the False Claims Act include:

The Medicare Program

Medicare is a federally-funded health insurance program that covers certain medical expenses for individuals who are either over 65, disabled, or  diagnosed withEnd Stage Renal Disease. The Medicare program is administered through the Department of Health and Human Services, Centers for Medicare and Medicaid Services (“CMS”).

The Medicare program has four parts: A, B, C, and D. Medicare Part A , the Basic Plan of Hospital Insurance, covers the cost of inpatient hospital services and post-hospital nursing facility care. Medicare Part B, the Voluntary Supplemental Insurance Plan, covers the cost of physicians and certain other health care provider servicesincluding those provided by laboratories and diagnostic testing facilities. Medicare Part C covers certain managed care plans, and Medicare Part D provides subsidized prescription drug coverage for Medicare beneficiaries.

The Medicaid Program

Medicaid is a public assistance program that covers medical expenses for low-income and disabled patients.  Funding for Medicaid is shared between the Federal Government and states participating in the program.

Veterans’ and Department of Defense Health Care Programs

The Veterans Health Administration is America’s largest integrated health care system, with over 1,700 sites of care, it serves 8.76 million veterans each year. The Veterans Administration (“VA”) purchases as wide a range of healthcare related products and services as any healthcare system in the world.

When a veteran’s local VA healthcare facility cannot provide adequate services, the veteran may be eligible to receive services from non-VA physicians, hospitals, or other providers through the Veterans Choice Program (VCP).

Another healthcare program funded by the VA, called CHAMPVA, provides healthcare for the families of veterans with a 100% service-connected disability.

TRICARE/CHAMPUS is a health care program for individuals and dependents affiliated with the armed forces.

Other Government-Funded Healthcare Programs

The Federal Employee Health Benefit Program (also known as “FEP”), administered by the United States Office of Personnel Management, provides health insurance for federal employees, retirees, and survivors. Individual states provide similar healthcare programs for state employees, retirees, and survivors.

The United States and various states also provide healthcare coverage through programs related to workplace injuries and/or health issues, including Worker’s Compensation Programs, and specific programs for energy workers, longshoremen, and miners, among others.

To find out more about whether a particular type of fraud is covered by the False Claims Act, contact us today.