Fraud in Healthcare Agencies Us





One of the main problems facing healthcare sector is fraud. In 2015 alone in US, about $2.27 trillion was spent on healthcare and over four billion dollars on health insurance claims. It is true that some of the health insurance claims were fraudulent. Although they may constitute a small fraction, the fraudulent claims carry a high price tag. This paper will discuss fraud in healthcare agencies US.
According to national Health Care Anti-Fraud Association (NHCAA), it is estimated that the financial losses as a result of healthcare fraud are over ten of billion dollars yearly. No matter one has employer-sponsored health insurance or even your own insurance policy, healthcare fraud unavoidably translates into elevated premiums and thus out-of-pocket expenses for consumers, resulting to reduced benefits (Vian, 2008). For employers-private as well as government, healthcare fraud elevates the costs of providing insurance benefits to the employees and thus increases overall cost of business. For numerous Americans, increased expenses resulting from fraud means difference between making health insurance a reality and not (Diamond, 2008).
Financial losses brought by healthcare frauds are only part of a long story. Healthcare fraud has human face too. Individual sufferers of healthcare fraud are always sadly easy to find. These are many people who are exploited and thus subjected to needless and unsafe medical dealings. Or whose medical records are compromised or legitimate insurance information is used to submit falsified claims.
Majority of healthcare fraud is committed by a small minority of deceitful health care providers. Sadly, their actions ultimately serve to sully reputation of the most trusted and respected members of the society. Regrettably, the stock in trade of fraud-doers is to take benefit of assurance entrusted to them so as to commit fraud on broad scale, and by conceiving fraud schemes, the group has luxury of being creative since it has access to vast range of variables with which to conceive all sorts of wrongdoing:
The most common types of fraud committed by dishonest providers are (Vian, 2008):
· Billing for services that were never rendered-either by using genuine patient information, sometimes obtained through identity theft, to fabricate entire claims or by padding claims with charges for procedures or services that did not take place.
· Billing for more expensive services or procedures than were actually provided or performed, commonly known as “up coding”-i.e., falsely billing for a higher-priced treatment than was actually provided (which often requires the accompanying “inflation” of the patient’s diagnosis code to a more serious condition consistent with the false procedure code).
· Performing medically unnecessary services solely for the purpose of generating insurance payments-seen very often in nerve-conduction and other diagnostic-testing schemes
· Misrepresenting non-covered treatments as medically necessary covered treatments for purposes of obtaining insurance payments-widely seen in cosmetic-surgery schemes, in which non-covered cosmetic procedures such as “nose jobs” are billed to patients’ insurers as deviated-septum repairs.
· Falsifying a patient’s diagnosis to justify tests, surgeries or other procedures that aren’t medically necessary
· Unbundling – billing each step of a procedure as if it were a separate procedure.
· Billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit plan under the terms of a managed care contract.
· Accepting kickbacks for patient referrals.
· Waiving patient co-pays or deductibles for medical or dental care and over-billing the insurance carrier or benefit plan (insurers often set the policy with regard to the waiver of co-pays through its provider contracting process; while, under Medicare, routinely waiving co-pays is prohibited and may only be waived due to “financial hardship”).
Much the same as other fraud forms, Health frauds, requests that false data be spoken to truth. A very basic human services extortion conspire includes culprits who abuse patients by going into their restorative records bogus analyses of medicinal conditions they don’t have, or of more extreme conditions than they really do have. This is done as such that false protection cases can be submitted for installment (Diamond, 2008).
A Boston-range specialist, for instance, relinquished $1.3 million and was sentenced to quite a long while in government jail after his late-1990s conviction on 136 checks of mail extortion, IRS evasion and witness terrorizing identified with his fake charging of a few wellbeing back up plans for psychiatric treatment sessions that never occurred utilizing the names and protection data of numerous individuals whom he really had never met, not to mention treated. In creating the cases, the specialist likewise made analyses for those “patients”- a large number of them young people. The imposter conditions he alloted to them included “depressive psychosis,” “self-destructive ideation,” “sexual personality issues” and “behavioral issues in school (Blumstein, 2006).”
Healthcare fraud has many effects. Patients who have private medical coverage regularly have different cutoff points on advantages under their arrangements. So every time a false claim is paid in a patient’s name, the dollar sum checks toward that patient’s lifetime or different breaking points. This implies when a patient authentically needs his or her protection benefits the most, they may have as of now been depleted (Diamond, 2008).
At the point when one’s name or other distinguishing data is utilized without that individual’s learning or agree to acquire medicinal administrations or products, or to submit false protection claims for installment, that is restorative fraud. Medicinal data fraud as often as possible results in wrong data being added to a man’s restorative record, or even the making of a completely invented therapeutic record in the casualty’s name. Casualties of restorative fraud may get the wrong therapeutic treatment, find that their medical coverage benefits have been depleted, and could get to be uninsurable for both life and medical coverage scope (Blumstein, 2006).
Unwinding the web of misleading spun by culprits of restorative fraud can be an exhausting and distressing attempt. The impacts of this wrongdoing can torment a casualty’s medicinal and money related status for a considerable length of time to come (Diamond, 2008).
The fraud also has physical risks. Shockingly, the culprits of fraud extortion conspires intentionally and unfeelingly put trusting patients at critical danger of damage or even passing. It’s troubling to envision, however there have been numerous situations where patients have been subjected to pointless or hazardous therapeutic methodology basically in view of ravenousness. In June, 2002, for instance, a Chicago cardiologist was sentenced to 12 years in government jail and was requested to pay $16.5 million in fines and compensation subsequent to conceding to performing 750 restoratively pointless heart catheterizations, alongside superfluous angioplasties and different tests as a component of a 10-year extortion plot. Three different doctors and a clinic head additionally confessed and got jail sentences as far as concerns them in the plan, which brought about deaths of not less than two patients (Blumstein, 2006).
Human services Fraud and Organized Criminal Groups are very common. Healthcare fraud is not simply dedicated by exploitative healthcare insurance suppliers. The country is constantly developing pool of medicinal services fraud raiders in specific regions – Florida, for instance – law offices and healthcare insurance providers have seen as of late the relocation of culprits from unlawful medication trafficking into the more secure and significantly more lucrative business of executing misrepresentation plans against Medicare, Medicaid and private medical coverage organizations. In South Florida alone, government projects and private healthcare providers have lost countless dollars as of late to criminal rings – some of them situated in Central and South America – that create claims from non-existent facilities, utilizing authentic patient-protection and supplier charging data that the culprits have purchased or potentially stolen for that reason. At the point when the false claims are paid, the street number in many occasions has a place with a cargo forwarder that wraps up the mail and ships it seaward.
Federal Crime has Stiff Penalties for fraud. Congress-through the Health Insurance Portability and Accountability Act of 1996 (HIPAA)-specifically established health care fraud as a federal criminal offense, with the basic crime carrying a federal prison term of up to 10 years in addition to significant financial penalties. United States Code, Title 18, Section 1347. The federal law also provides that should a perpetrator’s fraud result in the injury of a patient, the prison term can double, to 20 years; and should it result in a patient’s death, a perpetrator can be sentenced to life in federal prison (Vian, 2008).
Congress also mandated the establishment of a nationwide “Coordinated Fraud and Abuse Control Program,” to coordinate federal, state and local law enforcement efforts against health care fraud and to include “the coordination and sharing of data” with private health insurers (Blumstein, 2006).
Many states also have responded vigorously since the early 1990s, not only by strengthening their insurance fraud laws and penalties, but also by requiring health insurers to meet certain standards of fraud detection, investigation and referral as a condition of maintaining their insurance or HMO licenses (Diamond, 2008).
Private-Public Cooperation is also against Fraud. Founded in 1985 by a handful of private insurers and law enforcement personnel, the National Health Care Anti-Fraud Association is a private-public non-profit organization focused solely on improving the private and public sectors’ ability to detect, investigate, prosecute and, ultimately, prevent fraud against our private and public health insurance systems.
Today NHCAA represents the combined efforts of the anti-fraud units of the majority of our country’s private health payers and the entire spectrum of federal and some state law enforcement agencies that have jurisdiction over the crime, along with hundreds of individual members from the private health insurance sector and from federal, state and local law enforcement.
The NHCAA pursues its mission by fostering private-public cooperation against health care fraud at both the case and policymaking levels, by facilitating the sharing of investigative information among health insurers and law enforcement agencies and by providing information on health care fraud to all interested parties (Blumstein, 2006).
The NHCAA Institute for Health Care Fraud Prevention, a non-profit educational foundation, provides professional education and training to industry and government anti-fraud investigators and other personnel.
To protect yourself from fraud, you have to protect your health insurance ID card like you would a credit card. In the wrong hands, a health insurance card is a license to steal. Don’t give out policy numbers to door-to-door salespeople, telephone solicitors or over the Internet. Be careful about disclosing your insurance information and if you lose your insurance ID card, report it to your insurance company immediately.
In case of Report fraud, Call your insurance company immediately if you suspect you may be a victim of health insurance fraud. Many insurers now offer the opportunity to report suspected fraud online through their Website. Also be informed. Be informed about the health care services you receive, keep good records of your medical care, and closely review all medical bills you receive.
One should also read policy and benefits statements. Read your policy, Explanation of Benefits (EOB) statements and any paperwork you receive from your insurance company. Make sure you actually received the treatments for which your insurance was charged, and question suspicious expenses. Are the dates of service documented on the forms correct? Were the services identified and billed for actually performed? (Diamond, 2008).
Beware of “free” offers. Is it too good to be true? Offers of free health care services, tests or treatments are often fraud schemes designed to bill you and your insurance company illegally for thousands of dollars of treatments you never received.
Health care fraud is a serious crime that affects everyone and should concern everyone-government officials and taxpayers, insurers and premium-payers, health care providers and patients-and it is a costly reality that none of us can afford to overlook.

Vian, T. (2008). Review of corruption in the health sector: theory, methods and interventions. Health policy and planning, 23(2), 83- 94.
Blumstein, J. F. (2006). Fraud and Abuse Statute in an Evolving Health Care Marketplace: Life in the Health Care Speakeasy, The. Am. JL & Med., 22, 205.
Diamond, L. (2008). The democratic rollback: the resurgence of the predatory state. Foreign affairs, 36-48.

Did it help you?

Cite this Page

Fraud in Healthcare Agencies Us. (2022, Feb 21). Retrieved from

Need customer essay sample written special for your assignment?

Choose skilled expert on your subject and get original paper with free plagiarism report

Order custom paper

Without paying upfront