Fraud in Healthcare Agencies US Essay Example

dishonest providers include billing for services that were never performed, using patient information acquired through identity theft, or padding claims with false charges. They also engage in "up coding," where they bill for expensive procedures or services that were not actually provided, often coupled with falsely inflating the patient's diagnosis code.

Some examples of these fraudulent activities include performing unnecessary medical services solely to generate insurance payments, commonly observed in nerve-conduction and other diagnostic-testing schemes. Additionally, there are instances where non-covered treatments are misrepresented as medically necessary covered treatments in order to obtain insurance payments, which is frequently seen in cosmetic-surgery schemes.The text highlights various fraudulent practices in billing patients' insurers. These include charging non-covered cosmetic procedures as deviated-septum repairs, falsifying diagnoses to justify unnecessary tests or surgeries, unbundling procedure steps as separate procedures, overcharging patients for prepaid services, accepting kickbacks for patient referrals, and waiving co-pays or deductibles while over-billing the insurance carrier. It is important to note that while insurers determine co-pay policies through provider contracts, Medicare strictly prohibits routine co-pay waivers unless there is a "financial hardship."

Health fraud involves the presentation of false information as truth, similar to other forms of fraud. In healthcare fraud, one common scheme is manipulating patients' medical records by providing false diagnoses or exaggerating their actual conditions. This manipulation aims to submit false insurance claims for payment (Diamond, 2008). An example is a doctor in Boston who was convicted in the late 1990s on 136 counts of mail fraud, tax evasion, and witness intimidation. He billed multiple health insurers for nonexistent psychiatric treatment sessions using the names and insurance information of individuals he had never met or treated.

As a result, he forfeited $1.3 million and received a federal prison sentence for several years.

In the process of creating cases, the specialist also conducted analyses for these "patients" - many of whom were young individuals. The false conditions he assigned to them consisted of "depressive psychosis," "suicidal ideation," "sexual identity disorders," and "school behavioral issues (Blumstein, 2006)." Healthcare fraud has numerous consequences. Patients with private medical coverage typically have various limits on benefits outlined in their plans. Therefore, whenever a fraudulent claim is reimbursed under a patient's name, the monetary amount contributes towards that patient's lifetime or other specific limits.

When a patient requires their protection benefits the most, they may already have been exhausted (Diamond, 2008). If someone obtains medical services or products using another person's name or personal information without their knowledge or consent, or makes false insurance claims for payment, it is considered medical fraud. Medical identity theft often results in inaccurate information being added to an individual's medical record or even the creation of a completely fabricated medical record under the victim's name. Victims of medical fraud may receive incorrect medical treatment, discover that their health insurance benefits have been depleted, and could become ineligible for life and health insurance coverage (Blumstein, 2006). Untangling the deceptive web woven by perpetrators of medical fraud can be a challenging and stressful task.

According to Diamond (2008), the misconduct discussed here can cause serious and long-term harm to a victim's well-being and financial stability. Additionally, this fraud also poses physical risks. Regrettably, the individuals responsible for these deceitful plans deliberately and mercilessly endanger unsuspecting patients, exposing them to significant harm or potential fatality. It is

distressing to contemplate, but numerous incidents have occurred where patients have undergone unnecessary or hazardous medical procedures solely driven by greed.

In June of 2002, a Chicago cardiologist received a conviction and a 12-year prison sentence after admitting to performing 750 medically unnecessary heart catheterizations, as well as other unnecessary tests and angioplasties. This fraudulent scheme lasted for ten years and resulted in the deaths of at least two patients. Additionally, three other doctors and a hospital executive pleaded guilty and were also sentenced to prison for their involvement in this scheme (Blumstein, 2006). Healthcare fraud is not limited to untrustworthy healthcare insurance providers; it occurs frequently.

Healthcare fraud operations are increasing in specific regions such as Florida. Law firms and healthcare insurance providers have observed a trend where criminals formerly involved in illegal drug trafficking are now targeting Medicare, Medicaid, and private health insurance companies for fraudulent schemes. In South Florida alone, government programs and private healthcare providers have experienced significant financial losses due to criminal organizations from Central and South America. These organizations acquire legitimate patient-protection and provider billing information through purchase or theft, which is then utilized to create false claims. Once payment for these deceitful claims is received, they often employ the address of a cargo forwarder before transferring the funds internationally. It is crucial to acknowledge that engaging in federal fraud carries severe consequences.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) criminalized health care fraud, making it punishable under federal law. Offenders can face prison sentences ranging from 10 to 20 years, as well as significant financial penalties (United States Code, Title 18, Section 1347). If the fraud leads to

patient injury, the prison term can be extended to 20 years. In cases where patient death is caused by fraud, the perpetrator may be sentenced to life imprisonment in a federal facility (Vian, 2008). Congress also required the establishment of a nationwide "Coordinated Fraud and Abuse Control Program" that aims to coordinate efforts between federal, state, and local law enforcement agencies in combating health care fraud. This program involves sharing data with private health insurers (Blumstein, 2006).

Since the early 1990s, many states have implemented measures to address insurance fraud. These measures involve strengthening laws and penalties for insurance fraud and imposing specific requirements on health insurers to maintain their licenses (Diamond, 2008).

The National Health Care Anti-Fraud Association was established in 1985 by private insurers and law enforcement personnel to combat fraud against health insurance systems. Its mission is to enhance prevention, detection, investigation, and prosecution of fraud. The association consists of anti-fraud units from major private health payers nationwide, as well as federal and some state law enforcement agencies. It also has individual members from the private health insurance sector and various levels of law enforcement agencies.

The NHCAA's main objective is to combat health care fraud by promoting collaboration between public and private sectors. This includes facilitating the exchange of investigative information between health insurers and law enforcement agencies, as well as providing relevant information on health care fraud to interested parties (Blumstein, 2006). The NHCAA Institute for Health Care Fraud Prevention, a non-profit educational foundation, offers professional education and training for industry and government anti-fraud investigators and other personnel. It is important to protect your health insurance ID card just like you would safeguard

a credit card because if it falls into the wrong hands, it can be used for fraudulent activities.

When providing policy numbers to door-to-door salespeople, telephone solicitors, or online, it is crucial to exercise caution. It is also important to be cautious when sharing insurance information and promptly inform your insurance company if you misplace your insurance ID card. If you believe that you have fallen prey to health insurance fraud, it is recommended that you promptly reach out to your insurance company. Nowadays, numerous insurers offer the ability to report suspected fraud on their website.

Staying informed about your health care services and keeping detailed records of your medical care is crucial. Take the time to thoroughly review all medical bills you receive and ensure that you understand your policy and benefits statements. Carefully read through your policy, Explanation of Benefits (EOB) statements, and any other paperwork provided by your insurance company. Confirm that the treatments for which your insurance was billed were actually received and question any expenses that appear suspicious. Verify that the dates of service recorded on the forms are accurate and make sure that the services identified and billed for were indeed performed (Diamond, 2008).

Warning: It is important to be cautious of offers that claim to be "free" as they may not be legitimate. If something seems too good to be true, it probably is. These types of offers often involve fraudulent schemes that result in illegal charges being made to you and your insurance company for expensive treatments that you never actually receive. Health care fraud is a serious crime that affects everyone and should concern all individuals involved including government

officials, taxpayers, insurers, premium-payers, health care providers, and patients. This issue is a costly reality that cannot be ignored.

References

• 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 resurgence of the predatory state: the democratic rollback. Foreign affairs, 36-48.