Medicare/Medicaid Fraud

Identity Fraud Scenario

Not Exactly What the Doctor Ordered.

health-care-promoMedicare and Medicaid are landmark programs that help pay medical costs for low-income, elderly, and disabled populations.





  • According to the Health Care Cost Institute (HCCI), costs between 2010 and 2011 alone rose 4.6%, a 21 % increase from the previous year.

  • The National Health Care Anti-Fraud Association estimates conservatively that 3% of all health care spending — or $70 billion — is lost to health care fraud each year.

  • Health care industry experts have estimated that if the U.S. health care system uses big data to drive efficiency and quality, it could generate annual health care savings of more than $300 billion.

Medicare and Medicaid Fraud occurs through a number of schemes including, but not limited to: Providers billing for services not provided; providers falsifying credentials; pharmacies substituting generic drugs, but billing Medicare and Medicaid for name-brand medications; identity theft of individuals; and identity theft
of providers.

Contributors to Medicare and Medicaid Fraud like organized crime use complex billing and referral schemes that make it difficult to detect and identify. To stem the rising tide and cost of fraud, waste and abuse, health care payer organizations need easy access to comprehensive, yet detailed information and analytics that creates a true picture of all their claims.

Fraud and abuse of health care services cost the U.S. about $125 to $175 billion per year, with Medicare and Medicaid fraud and abuse costing taxpayers about $98 billion per year.

Unfortunately, only 3-5 percent of fraud is actually detected.

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