Medicare and the affordable care act: Fraud control efforts and results

ABSTRACT

Medicare fraud and abuse costs are estimated at 3–10% of overall Medicare spending, which is expected to expand considerably until 2024 and as such the amount of fraud dollars would be expected to increase proportionally. The purpose of this research was to determine how recent reforms, especially the Patient Protection and Accountable Care Act, may affect Medicare fraud and abuse and to uncover the best strategies to combat Medicare fraud. Methodology: the methodology for this qualitative study was a literature review. Seven electronic databases and five websites were utilized. Fifty-six sources were referenced for this literature review. The breadth of fraud and abuse within Medicare as well as recent reforms to fight fraud including legislative reforms, delivery system reforms, and other reforms including the formation of HEAT fraud fighting taskforces are examined. Legislative reforms are noted to be incompatible with the ACA’s new P4P delivery and reimbursement reforms. Medicare fraud requires comprehensive detection and prevention measures. Benefits of implementing this dual method of fraud fighting are discussed.

KEYWORDS:

• Medicare fraud
• medicare expenditure
• fraud design
• ACA
• healthcare fraud law

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes on contributors

Sarah Clemente, MHA Alumni. Healthcare Administration Program, Management and Healthcare Division, Lewis College of Business, Marshall University.

Ronald McGrady, MHA. Healthcare Administration Program, Management and Healthcare Division, Lewis College of Business, Marshall University.

Robert Repass, MHA. Healthcare Administration Program, Management and Healthcare Division, Lewis College of Business, Marshall University.

David P. Paul, III, D.D.S., M.B.A., Ph.D., M.A. Professor of Marketing and Health Care Management, Leon Hess Business School, Monmouth University.

Alberto Coustasse Professor. Dr. PH. MD, MBA, MPH, Healthcare Administration Program, Management and Healthcare Division, Lewis College of Business, Marshall University.