Speculations on Medicaid Fraud in the New Year

The year 2018 has ushered in immense changes in government policy, with President Donald Trump and his administration’s attempt to reform healthcare coverage for Americans nationwide under the Affordable Care Act, or Obamacare. These new changes could affect the number of Medicaid fraud cases this year.


Medicaid Fraud Statistics of 2017

Any abuse of Medicaid, a federal program that provides health care assistance to those who have disabilities or low income, is illegal, and the abuser will be punished by the law. There are many types of Medicaid abuses including billing for unnecessary services or services that weren’t provided, unpackaging services in order to raise prices, lying about the patients treated, and more.

The Coalition Against Insurance Fraud estimated that in 2017, about $80 billion were stolen by insurance fraud. In 2016, there were 18,730 Medicaid investigations: 1,721 of them led to charges or indictments, 1,564 of the cases involved conviction, and 998 cases were settled or judged. In an 2017 opioid-related case, also known as the “largest fraud takedown in history”, more than 400 people in the United States were charged for health care fraud, resulting in over “$1.3 billion in false Medicare and Medicaid billings”. Health care providers, including 50 doctors, had billed Medicaid for false treatments, drugs that weren’t purchased in return for cash, and giving unnecessary opioid prescriptions, which only harmed opioid addicts and led to rising drug overdose deaths. A report propose that this could be a result of Medicaid expansion. The prescription of opioid was decreasing slightly since 2012, but after the first four years of Medicaid expansion, there was an increase of 55 percent of criminal cases. It is possible that there is a relationship between Medicaid expansion and opioid prescription leading to increased Medicaid fraud cases.

Attorney General Jeff Sessions noted that large case is one reason why the Trump’s administration is imposing stricter sentences in an attempt to stop drug crime. President Trump has also decided to lower fraud crimes by investing $70 million in the health care fraud control program. Could his efforts potentially lower the amount of Medicaid fraud crimes in the near future?

More Affordable Plans and More Consumer Options?

In the previous administration, Obamacare premiums doubled in price, many insurers stopped working with Obamacare, the health plans of millions of Americans were cancelled because they weren’t approved, and billions of dollars in fines were paid as a result of Obamacare tax.

This led to a decline in Obamacare enrollment.

President Trump took office 2017 and attempted to repeal Obamacare, but failed. Instead, he ended up proposing changes to Obamacare. President Trump signed an executive order that expands access and provides more options and alternatives to health insurance by allowing people to purchase health insurance across state lines. This expands people’s access to “association health plans” provided by small businesses, giving people the option to choose the insurance that may be more affordable or accustomed to one’s needs. Although supporters of this plan claim that it will lower costs as a result of competition, critics believe that the plan will raise costs for premiums and sick people will end up searching for lower-cost plans that have fewer benefits.

The Obamacare open enrollment for 2018 has other significant changes. Trump’s administration had cut the enrollment period in half from twelve weeks to six weeks. Those who do not select a plan by December 15 cannot switch to another plan after that date, and they will be automatically re-enrolled in their current plan or a similar one if it is no longer continued. This shortened timeline also results in less time allocated to advertising, navigating, and helping people sign up for Obamacare. In addition, there are no longer plans for promotional events in states. Although this could result in significantly less people signing up for Obamacare or being aware of the changes of this program(the Kaiser poll found that only 25% of enrollees and 5% of the uninsured knew when the enrollment period ends), the Department of Health and Human Services’ officials stated that customers will receive reminders and notices to shop for health care plans and to not miss the December 15 deadline.

Trump’s administration had also adjusted the ways customers can purchase Obamacare plans. Customers can now shop for Obamacare plans on healthcare.gov website with the display of the plans that are available to them and the costs of such plans. Brokers and agents will also be available online to aid customers, at their convenient time, in buying plans and providing advice. Furthermore, customers could also purchase Obamacare plans through its partner or third-party websites such as ehealthinsurance.org. However, the downside is that there are fewer health care coverages this year especially in less populated rural areas, which may only have one insurer, and no choices.

How Does President Trump’s Plan Affect You?

It is true that your health care costs could be lowered if you are healthy. Trump’s removal of mandate by signing of the Tax Cuts and Jobs Act repeals the Obamacare tax for those who do not receive health insurance. This may result in fewer Medicaid enrollment because people would think that they no longer need health insurance, nor would they check to see if they are eligible. Fewer Medicaid enrollments can also impact hospitals, as they will lose customers and the amount of money paid for hospital bills will also be significantly less. Eventually, the prices for hospital services would rise in order for hospitals to be financially stable.

Another noteworthy knowledge is that the option of purchasing a short-term or association health plan may be cheaper, but it offers less than the 10 ACA benefits. Most healthy people would choose the latter option and purchase cheaper health plans. CBO estimated that 13 million people would drop coverage, which would only raise the prices of premiums for those who are sick and old. This defeats the goal of ACA, which is meant to eliminate the differences in coverage. Fewer people will seek treatment for chronic diseases or purchase health care for preventing diseases, which may result in a health crisis. Furthermore, in the case that you have a chronic illness or become sick, the cost of Obamacare may be much higher especially if you exceed your plan’s annual limit.

The Future of Medicaid

Agreed upon by 60% of insurers, insurance fraud has only increased over the last three years, and many insurers do not feel protected against fraud. However, could President Trump’s efforts to reform Obamacare and invest in controlling Medicaid fraud bring balance to the system? With millions of newcomers applying for public healthcare, human error is unavoidable; thousands of Americans will misreport their medical records, or miss the deadlines to file their proof of income. Only one thing is certain as we learn alongside our national leaders – adequate legal counsel will continue to be a necessity.