Date of Award

2020

Degree Name

Healthcare Administration

College

College of Business

Type of Degree

M.S.

Document Type

Research Paper

First Advisor

Alberto Coustasse

Abstract

Introduction: The Affordable Care Act (ACA) increased access to health insurance throughout the United States. To date, an estimated 20 million previously uninsured individuals have gained access to coverage since the expansion. As a result, the number of fraudulent schemes reported has been on the rise. Among the many fraudulent activities in the healthcare sector, abuse of pharmacy benefits has been the most prevalent. The misuse and abuse of opioids, and opioid related overdoses has created a widespread epidemic throughout the country, thus extending opportunities for potential fraud within the pharmaceutical industry.

Purpose of the Study: The purpose of the study was to determine if healthcare fraud has increased as an unintended consequence of ACA. Operating with the assumption that with greater access could have created an unintended incentive and greater opportunities for fraud. The focus was on provider and pharmacy fraud because they are the principal gatekeepers that control access to the supply that manufacturers must meet.

Methodology: The methodology for this qualitative study utilized a literature review. Eight databases were used to collect 1427 articles, studies, or abstracts. These sources were reviewed and reduced to 39 sources which were included in the written research. Of these, 20 were used in the results section.

Results: The results indicated that along with the expansion of Medicaid, outpatient prescriptions from Medicaid patients had risen. In order to deal with the influx of participants, a variety of changes in Medicaid programs have been considered or enacted to respond to the challenges arising.

Discussion/ Conclusion: The research illustrated that both Medicaid fraud and opioid misuse has become more prevalent since the enactment of the ACA by providers and patients. Fraud, as well as opioid misuse and abuse in Medicaid has cost states billions of dollars each year. Moreover, there has been a concerted effort to increase vigilance in preventing drug diversion and fraud. Key Words: Medicaid, Centers for Medicare and Medicaid Services (CMS), opioid, pharmacy, prescriptions, prescribers, Affordable Healthcare Act (ACA).

Subject(s)

United States. Patient Protection and Affordable Care Act.

Opioid abuse -- United States.

Drugs -- Prescribing -- Corrupt practices -- United States.

Medicaid fraud.

Health services administration.

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