ADS Capstone Chronicles Revised

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It results in tens of billions of dollars in yearly losses, affecting health insurance premiums, exposing individuals to unnecessary medical procedures, and increasing taxes (Federal Bureau of Investigation [FBI], n.d.). This crime is committed by medical providers, patients, and others who deceive the healthcare system for unlawful benefits or payments (FBI, n.d.). According to the Centers for Medicare & Medicaid Services (CMS) (2021), FWA can lead to substantial financial losses and a decrease in quality of care. The CMS (2021) has outlined that fraud involves knowingly providing false information to obtain unauthorized benefits such as creating prohibited referrals, while waste refers to the misuse of resources, and abuse entails practices that are inconsistent with accepted standards, leading to unnecessary costs to the Medicare Program. This project aims to uncover such issues by analyzing service utilization patterns and provider density, thus providing actionable insights for policymakers and healthcare providers to enhance service delivery and patient outcomes, reducing FWA. 2 Background Globally, healthcare systems struggle with efficient resource management. In the United States, understanding Medicare market saturation is essential for assessing how provider density impacts healthcare utilization and FWA. Per the Centers for Medicare & Medicaid Services (2024), market saturation refers to the concentration of healthcare providers compared to the beneficiary population in a specific area. High saturation can signal potential FWA

and increased service use, while low saturation may indicate insufficient service availability. The CMS Market Saturation and Utilization Data Tool (2024) provides valuable data for understanding these patterns. This dataset is crucial for understanding market saturation dynamics and its impact on resource allocation. According to the Medicare Medicaid Coordination Office (2023), among dually eligible individuals, 51% were enrolled in Medicare managed care in 2021, a significant increase from 22% in 2012. Additionally, 29% of individuals who transitioned to full-benefit dual eligibility from 2007-2009 lost Medicaid coverage for at least one month, and 21% lost coverage for more than three months during the 12-month follow-up period. These metrics Healthcare fraud, including double billing, phantom billing, unbundling, and upcoding by medical providers, as well as identity theft or bogus marketing by patients, adds to these inefficiencies. Fraud involving prescriptions, such as forgery, diversion, and doctor shopping, further complicates the landscape (FBI, n.d.). Addressing these issues can prevent poor service quality, high costs, and suboptimal health outcomes. 2.1 Problem Identification and Motivation The imbalance in healthcare resource distribution often leads to FWA in reflect the challenges of managing healthcare resources and addressing potential inefficiencies.

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