It includes any payment to an ineligible recipient, any payment for an ineligible service, any duplicate payment, payments for services not received…. * In 2011, GAO reported the results of an investigation meant to “determine the extent to which Medicare beneficiaries obtained frequently abused drugs from multiple prescribers.” This is sometimes called “doctor shopping,” and it is one of the primary ways in which people “obtain highly addictive” prescription drugs “for illegitimate use.” The investigation found that: about 170,000 Medicare beneficiaries received prescriptions from five or more medical practitioners for the 12 classes of frequently abused controlled substances and 2 classes of frequently abused noncontrolled substances in calendar year 2008.
But when analyzing the effects of preventive care on total spending for health care, it is important to recognize that doctors do not know beforehand which patients are going to develop costly illnesses.
To avert one case of acute illness, it is usually necessary to provide preventive care to many patients, most of whom would not have suffered that illness anyway. Judging the overall effect on medical spending requires analysts to calculate not just the savings from the relatively few individuals who would avoid more expensive treatment later, but also the costs for the many who would make greater use of preventive care. Although effective obesity prevention leads to a decrease in costs of obesity-related diseases, this decrease is offset by cost increases due to diseases unrelated to obesity in life-years gained.
The fraud schemes are not specific to any area, but they are found throughout the entire country.
The schemes target large health care programs, public and private, as well as beneficiaries.
Such entities are called “third-parties” because they typically do not deliver or receive the healthcare (i.e., they are not the patients or doctors).