Health and Human Services Actions

An Undergraduate Honors Thesis by
Emily Fisher
V449
Professor Nicole C. Quon
April 2008

ABSTRACT
Health care fraud is an important and visible factor associated with increasing health care
costs in the United States. Medicare and Medicaid contribute to a vast majority of those cost
sand therefore must be heavily scrutinized. This thesis will investigate the types of fraud, who
commits them, and why the health care system is more susceptible to fraud. More specifically,
the problems and complications of current fraud investigation for Medicare and Medicaid are
examined. This thesis will then evaluate how successful these initiatives were in reducing health
care fraud and explore new suggestions for preventing health care fraud in the future.

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REMEMBER, IF YOU ARE MIDDLE-CLASS YOU ARE JUST A HEARTBEAT AWAY FROM BEING ON MEDICAID. THIS SUPREME COURT RULING WILL MAKE IT IMPOSSIBLE FOR MANY EARNING $40,000 TO $90,000 HAVING A FAMILY TO AFFORD ANYTHING OTHER THAN CATASTROPHIC HEALTH COVERAGE MEANING POTENTIALLY CONSTANT HEALTHCARE INDEBTEDNESS. MARYLAND PRETENDS TO BE PROGRESSIVE, BUT IF YOU ACTUALLY LOOK AT WHAT IS DONE......MARYLAND IS NOT GOOD.

Total number of Providers in Maryland on Doctor.com who Accept Medicaid: 9
Top 10 Medicaid Provider Specialties in Maryland:

Physical Therapist (PT) (2 providers)
Nutritionist (1 providers)
Ophthalmologist (Eye Doctor) (1 providers)
Pediatrician (Kids / Children Specialist) (1 providers)
Neurologist (1 providers)
Radiologist (1 providers)
Family Doctor (1 providers)
Homeopath (Alternative Medicine) (1 providers)
Internist (1 providers)
Naturopath (Alternative Medicine) (1 providers)

States with the most Medicaid Doctors:

Cities with the most Medicaid Doctors:

Most popular medical specialty of providers who accept Medicaid in Maryland: Physical Therapist (PT) Medicaid providers in Maryland listed on Doctor.com have been practicing for an average of: 18 year(s) Average DocPoints™ score for providers in Maryland who take Medicaid: N/A Average Overall User Rating for providers in Maryland who take Medicaid: 5

Total number of Providers in Baltimore, MD on Doctor.com
who Accept Medicaid: 2 Top 10 Medicaid Provider Specialties in Baltimore, MD:

Radiologist (1 providers)
Family Doctor (1 providers)

States with the most Medicaid Doctors:

Cities with the most Medicaid Doctors:

Most popular medical specialty of providers who accept Medicaid in Baltimore, MD: Radiologist Medicaid providers in Baltimore, MD listed on Doctor.com have been practicing for an average of: 0 year(s) Average DocPoints™ score for providers in Baltimore, MD who take Medicaid: N/A Average Overall User Rating for providers in Baltimore, MD who take Medicaid: N/A

IF I WERE USING MEDICAID THIS IS THE ONE DOCTOR LIST FOR MY ZIP CODE. I DO NOT KNOW THE QUALITY OF SERVICE, BUT ONE MUST ASSUME THAT GIVEN THIS ZIP CODE HAS WHAT COULD BE THOUSANDS OF PEOPLE ON MEDICAID, YOU SEE THE PROBLEM. I AM TOLD TIME AND AGAIN THAT PATIENTS CALL ALL AROUND FOR APPOINTMENTS AND OFTEN ARE TURNED AWAY. SO, DO THEY HAVE COVERAGE?

THIS WOULD BE REMEDIED BY REQUIRING DOCTORS TO HAVE A PERCENTAGE OF THEIR CLIENTS AS MEDICAID JUST AS WITH MEDICARE. WHAT MARYLAND IS DOING IS HAVING JOHNS HOPKINS SET UP 'BOUTIQUE CLINICS' WHERE DOCTORS HAVE A DOZENS PATIENTS THAT PAY LARGE MEMBERSHIP FEES TO GET PREMIUM SERVICE. THIS IS WHY THEY ARE BRINGING IN IMMIGRANT DOCTORS AND HEALTHCARE WORKERS.

ALL AROUND THE CITY YOU ARE SEEING 'PATIENT FIRST' OR MEDSTAR HEALTH CLINICS IN UNDERSERVED COMMUNITIES. THEY CHARGE YOU $160 TO COME IN FOR A CONSULTATION, THE DOCTORS CAN ONLY WRITE PRESCRIPTIONS AND GIVE A CURSORY CHECKUP, AND THEN THEY TELL YOU TO SEE A PRIMARY CARE DOCTOR.....WHICH THERE ARE NONE FOR MEDICAID PATIENTS.

DOES THIS SOUND LIKE HEALTHCARE COVERAGE TO YOU?

Showing 1 of 1 Matching Family Doctors in 21218 who accept Medicaid health insurance Basic Provider Profiles
Dr. Steven Hankins, MD Family Doctor Primary Office Location
1515 W North Ave
Baltimore, MD 21217
Avg. Patient Rating
DocPoints™
30/80
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YOU NEED TO CALL AND ATTEND MEETING OF HEALTHCARE FOR ALL AND ASK THEM TO DO MORE COMMUNITY OUTREACH FOR COMMENTING. DO YOU HEAR FROM THEM ANNOUNCING PUBLIC COMMENT PERIODS FOR THESE HEALTH REFORM ISSUES? I HAVE THE MEETING SCHEDULES ON THIS SITE. THERE IS A COMMENT PERIOD FOR THIS BLUEPRINT THROUGH MID-JULY.

Draft Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges

Introduction

The Affordable Care Act establishes Affordable Insurance Exchanges (Exchanges) to provide individuals and small business employees with access to health insurance coverage beginning January 1, 2014.1 An Exchange is an entity that both facilitates the purchase of Qualified Health Plans (QHP) by qualified individuals and provides for the establishment of a Small Business Health Options Program (SHOP), consistent with Affordable Care Act 1311(b) and 45 CFR 155.20. Exchanges will provide competitive marketplaces for individuals and small employers to directly compare and purchase private health insurance options on the basis of price, quality, and other factors. Exchanges are integral to the Affordable Care Act’s goal of prohibiting discrimination against people with pre-existing conditions and insuring all Americans.

The Affordable Care Act provides States with significant flexibility in the design and operation of their Exchange to best meet the unique needs of their citizens and their marketplace. States can choose to operate as a State-based Exchange, or the Secretary of the Department of Health & Human Services (HHS) will establish and operate a Federally-facilitated Exchange in any State that does not elect to operate a State-based Exchange. In a Federally-facilitated Exchange, the State may pursue a State Partnership Exchange, where a State may administer and operate Exchange activities associated with plan management and/or consumer assistance. States that elect to participate in a State Partnership Exchange will administer these functions in both the individual and the small group market.

Regulations implementing the Affordable Care Act require HHS to Approve or Conditionally Approve State-based Exchanges no later than January 1, 2013, for operation in 2014. In addition, the Affordable Care Act 1321(c)(1) (B)(ii)(I) directs the Secretary to make a determination regarding whether the State will operate reinsurance and/or risk adjustment programs or will use Federal government services for these activities. To receive HHS Approval or Conditional Approval for a State-based Exchange or a State Partnership Exchange, as well as reinsurance and risk adjustment programs, a State must complete and submit an Exchange Blueprint that documents how its Exchange meets or will meet all legal and operational requirements associated with the model it chooses to pursue. As part of its Exchange Blueprint a State will also demonstrate operational readiness to execute Exchange activities.

Qualified Health Plans

Exchanges should be designed to provide qualified individuals and small businesses with access to an insurers’ qualified health plans. Qualified health plans or QHPs are described in the ACA as a type of health plan that is subject to a specified list of requirements related to marketing, choice of providers, plan networks, essential benefits, and other features. QHP issuers will have to be licensed by each state in order to be eligible to provide coverage within their boundaries, and offer at least one QHP at the silver or gold level of coverage.

Levels of Coverage

The ACA generally requires QHPs to provide coverage at one of the following levels: bronze, silver, gold, or platinum. Actuarial value (AV) is a measure of the percentage of expected health care costs a health plan will cover. Plans inside and outside the exchange in the individual and small group markets who offer non-grandfathered healthplans must offer plans that meet distinct levels of coverage specified in the ACA matching up to one of these "metal tiers" (and premiums must be the same for QHPs inside and outside of the Exchange). Excluding dental-only plans, health insurance issuers must offer a silver plan and a gold plan in the Exchange. Each coverage level will be based on a specified share of the full actuarial value of the essential health benefits. A health insurance issuer that offers coverage in any of these four levels will be required to offer the same level of coverage in a plan specifically designed for individuals under age 21.

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Health, Education, and Human Services Reform

ArticlesWith Comments Requested

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06/04/2012

06/05/2012