e., billing separately for groups of laboratory tests, resulting in higher reimbursements that would be the case if a single billing code applicable to the overall treatment was used). The latter three categories of fraud may occur either intentionally or because of errors in the interpretation of billing codes. Various billing codes established by the federal government apply to different diagnoses. An especially complex case, such as breast cancer, may involve several procedures. Providers must exercise care to assure that double billing, up-coding, and unbundling is not an outcome of the billing process (Price, 2002). The first two of the five categories are both the most numerous and the least defensible (Eaton, 2000).
Actions That the Cleveland Clinic Can Take to Combat Medicare Fraud
When health care fraud occurs, governmental agencies may prosecute under several different laws, including (a) the Social Security Act, (b) the False Statements Act, (c) generic criminal fraud statutes, or (d) any of several specific Medicare and Medicaid fraud statutes that target complex kickback arrangements and other sophisticated schemes to defraud. Conviction for such criminal violations can result in fines and/or imprisonment (Schofield & Weaver, 2000). Prosecutions for health care fraud typically are pursued as either (a) false claims or (b) false statements by health care providers.
As is true with any large institution such as the Cleveland Clinic, abuses of the Medicare system can occur. The Cleveland Clinic, however, has put into place effective controls to detect fraud (or errors) before billings are submitted to payers. This control system has been effective in keeping the Cleveland Clinic off the federal list of problematic p