Final paper:
During the course of this semester, you have learned about a number of ways the issue of health
care services fraud is addressed. Please take what you have learned in addressing the final project:
Scenario:
A potential health care fraud scheme has been discovered. It has been alleged that a doctor, “The
Candyman” has engaged in the practice of over prescribing a number of different prescription pain
medications. It is alleged that he has developed a practice which allows those with and without
insurance to appear at his office and receive prescriptions for pain medications without having to
go through the required examination process. It has even been suggested that he has a separate
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office within his practice for these patients to be “seen” so that they do not interfere with his
regular paying patient base. An initial review of the allegations seems to indicate the following:
• The Candyman has engaged in this practice for more than ten (10) years and has hundreds
of patients strictly receiving pain medication prescriptions without the benefit of going
through the required examinations.
• Many of these patients are on Medicaid, meaning that the Medicaid program is paying for
the prescriptions, and potentially for office visits that may not be occurring. At the same
time, there are many that have other insurance coverage, and some that simply pay with
cash.
• The vast majority of the prescriptions are being filled at one pharmacy, suggesting a
possible collusion.
• There may be as many as 50 patients that have died due to an overdose on pain medications
that have a direct tie to the Candyman’s practice.
In no more than five pages, I would like you to put together a plan for how to approach this
matter both from an oversight standpoint (what could be done to prevent this activity in the
future) and from an investigation standpoint (what steps should be taken and what
agency/agencies might need to be involved to investigate these allegations. As you are
thinking through this you should look at the different agencies we have discussed
throughout the semester, as well as the legal and investigative tools, in developing your
strategies.
There is no right or wrong answer. Your answer will be graded based upon the thought and support
given to each of your suggestions. And, I don’t expect you to approach it like a seasoned inspector
or investigator. I will be looking to see if you have gained an understanding of the various
alternatives that are available, and how well you understand them.
Readings
https://www.justice.gov/opa/pr/fact-sheet-health-care-fraud-and-abuse-control-program-protects-conusmers-and-taxpayers
https://www.cms.gov/medicare/medicaid-coordination/states/medicaid-integrity-program
https://healthpayerintelligence.com/news/preventing-provider-fraud-through-health-it-data-analytics
https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/
https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/FraudAbuseforProfs/Downloads/2008-Best-Practices-Medicaid-PI-Unit-Int-with-MFCU.pdf
https://oig.hhs.gov/compliance/
https://oig.hhs.gov/authorities/docs/cpghosp.pdf
https://www.govinfo.gov/content/pkg/CFR-2011-title42-vol5/pdf/CFR-2011-title42-vol5-part1007.pdf
