Research Paper On Healthcare Fraud

Committing medical coding fraud or abuse is extremely detrimental to the healthcare industry. They both lead to higher healthcare costs and an increase in the cost needed for medical coverage. In addition, the increasing discovers of these acts are putting a very negative light on healthcare workers, including those who are not committing either act. With the medical world being so complex we often instill and great amount of trust in the persons taking care of medical billing and coding, this trust also makes committing fraud and abuse easier for dishonest people to take advantage of.

Universal Healthcare sounds appealing, but it actually lowers the quality and quantity of healthcare services that are rendered to patients, thus downgrading the healthcare system as a whole.  Not having to pay, with everyone having coverage leads to longer wait times for medical service and many people overusing health care services. Implementation of Universal Healthcare in the United States would lead to a detrimental crippling of the nation’s health system. For those countries that have implemented Universal Healthcare or a system similar to it, all or most aspects of the coverage such as cost and care is generally provided by and tightly controlled by the government, a public-sector committee, or employer-based programs, with most of the funding essentially coming from tax revenues or budget cuts in other areas of spending. This paper will conclude with comparing the US healthcare system to others and how the US has one of the most advanced systems in the world.

On November 21, 2013, Theanna Khou pleaded guilty to dispensing and selling OxyContin from his Huntington Pharmacy without medical necessity from fraudulent prescriptions issued by a clinic (" Health care fraud investigations," 2014). Khou billed Medicare for filling prescriptions that patients never received. This story is becoming a norm for the health care industry, because the growing financial prosperity of the health industry. Corruption and crime is changing, turning from drug dealing to a safer haven that has less legal management, organization, and more wherewithal the business of health care fraud.

According to the American Hospital Association the cost of equipment, services, and information services has risen drastically. A huge problem for hospitals now is that there has been an enormous increase in patients who have Medicare or Medicaid. The Hospital Association states that “60% of all admissions. Neither program fully reimburses the cost of hospital care.” Not only is the hospital not getting paid the full amount through the health insurance, but they have also seen a jump in people who do not have insurance and cannot pay for their hospital expenses this averages out to about six percent of hospital expenses. Hospitals must assume these costs as a part of their charity pay. These costs are then calculated and increase the costs of health care for people who pay for it, in order to cover these costs.

According to the Federal Bureau of Investigation (FBI) “health care fraud costs the country an estimated $80 billion dollars a year” ("Health Care Fraud," n.d., p. 1). Because health care costs continue to rise more rapidly than the rate of inflation the threat of health care fraud continues to rise. The Affordable Health Care Act has put new policies in place to identify and stop health care fraud. The FBI along with other government, insurance, and public agencies have joined together to combat fraud at every level. New rules in identifying, investigating, and prosecuting fraud before payments are made to medical providers could save billions of

An issue that is widely discussed and debated concerning the United States’ economy is our health care system. The health care system in the United States is not public, meaning that the states does not offer free or affordable health care service. In Canada, France and Great Britain, for example, the government funds health care through taxes. The United States, on the other hand, opted for another direction and passed the burden of health care spending on individual consumers as well as employers and insurers. In July 2006, the issue was transparency: should the American people know the price of the health care service they use and the results doctors and hospitals achieve? The Wall Street Journal article revealed that “U.S. hospitals,

Collectively, the Department of Health and Human Services and the Department of Justice work to reduce healthcare fraud and investigate dishonest providers and suppliers. The Health Care Fraud Prevention and Enforcement Action Team recouped almost 3 billion in fraud, this year alone. Also, aggressive strategies exist to eliminate Medicare prescription fraud. Patients abusing or selling painkillers received by visiting several doctors and obtaining multiple prescriptions costs Medicare millions annually. Fraud affects everyone, preventing it requires government officials and citizens diligently working together.

(Jones and Jing) Though citizens might not see the effects of health care fraud directly, everyone is impacted in one way or another either through increased taxes, high insurance costs, or the inability to afford health care coverage. While we all hear about major frauds in the system, a majority of the frauds are small and usually go through undetected, unreported, or seriously underreported. (Sparrow) These small frauds add up to be a huge problem. There is a large spectrum of frauds in the health-care systems ranging from the theft of a wheelchair, to organized crime groups that steal patient information and bill for phantom services in multimillion-dollar schemes. (Jones and Jing) In many cases, the fraud is minor but all the small scams add up to an enormous loss to the public. For example, the frequent occurrences of forging of a doctor’s signature on a prescription accounts for billions of dollars lost each year. (Jones and Jing) One of the most common crimes involves billing for services that were never performed. This involves a health care provider submitting a false claim to be paid for a patient that was never treated or adding on services to a patient. For example a doctor may obtain names of other people such as a patients spouse or child who are covered by insurance and put in a claim for them as well as the actual patient. (FBI) Another common fraudulent activity involves upcoding of services. This is when a healthcare

Quality healthcare in the more rural areas of the United States is not only getting more difficult to obtain, but difficult to afford. American citizens living in rural areas have the highest rates of chronic disease, higher poverty populations, less health insurance, and there is less access to primary care physicians. When the economy is at its lowest point it causes an increase in a number of access and health issues that have already had prior problems in communities and in rural areas, therefore the main goal of the national health care tax of 2010 was to allow coverage to all residents of the United States, and also by transferring necessary health care to places that were farther away, such as the

Healthcare services have been on the rise for over 10 years now. According to a 2012 consumer alert, the industry provided $2.26 trillion in payments for more than four billion health insurance benefit claims in the year 2011(Fraud in Health Care). The bulk of the claims and the mainstream of fraud and abuse stem from the Medicare system professionals, who are knowledgeable about the process and persuade new clients into handing over their pertinent information in hopes of deception and illegitimate claims. Multiple and double billing, fraudulent prescriptions, are some of the major flaws in this organization that has made the healthcare services industry curdle. (AGHAEGBUNA, 2011) This is a non-violet crime and is often committed by very

Although Congress has used several anti-fraud measures to protect the federal government health care programs, the False Claims Act of 1986 has become the main weapon that government prosecutors use against perpetrators of health care fraud. Designed to prevent fraud and other abuses in federal government programs, the False Claims Act has been the primary statute the government has used in its fight against health care fraud. However, government prosecutors do not rely on one statute in their prosecution of alleged cases of health care fraud. Instead, they rely on a combination of statutes, but the False Claims Act has emerged as the main statutory weapon.

As the healthcare industry begins to expand its horizons, by featuring more staff and patients, the types of frauds that are committed also rise in number and complexity. One of the many consequences that derives from fraud within the healthcare system includes an increase in the cost of healthcare itself. In order to limit and analyze fraud that encompasses the entirety of the healthcare industry, it is necessary to assess the different types of frauds and in doing so also understand the method of reimbursement involving the professionals and members of the health care industry. Since a majority of these reimbursements are paid by insurances or through government programs, a program known as coding was created in order to organize and properly pay off these reimbursements(Marilyn Price, Donna Norris, 2009). One of the many

Healthcare is a major topic that is constantly being brought up in the news. It is often discussed within categories such as economics, politics, and policy. The reason that is, is because of healthcare's crucial role integration as part of each of these things. With that said, the United States has received back and forth opinions on the healthcare services that it offers. Karl Polanyi defines embeddedness as a way in which economic activity is constrained societies set of institutions (Tuttle 2018). So this implies that there are two main elements that are 'embedded' into the American culture, individualism and capitalism. These two elements shape the way the healthcare system is set up. Capitalism

These crooks are the possible cause of ruining the reputation of the most trusted and appreciated professionals of our society – physicians. Healthcare fraud can be committed in a variety of ways, but three of the most widely used are described below. The first and most widely known, is billing services that were never endured by using general patient information. When giving personal information out, many hand it over to the front desk assistant at the local doctor. These appear to be people are some of the most known to scam the information and bill patient’s payments that never took place. Keep in mind that when handing over information, the handler is a trusted individual with a good reputation. On the other hand, many are scammed for the opposite; otherwise known as “upcoding,” where patients are billed more expensive services that were actually done. In fact, according to USA.gov a new study showed that 7 percent of identity fraud victims this year reported identity thieves stole their health insurance information, rising up from just 3 percent last year (Federal Bureau Investigation, 2010). This includes the latest scam, called “unbundling,” where scammers con bills and bill each step of a procedure as if it were a separate making the individual pay even more money, leaving devastating effects for the victim. All of which have a common goal of making taxpayers, insurance companies, and

The healthcare system plays a key role in the economic stability of our country, as every year trillions are spent in attempt to combat disease and health issues that plaque humanity. As it makes up a significant amount of the expenditures in the economy, so the costs associated with health care of those in pain from illness and injury, including lost productivity, increased need of assistance in living and also the cost of death in some cases, is important to the economic stability and over all standard of living in our country. The key to economic prosperity is balancing the need for care with the costs of illness to keep as many people healthy and well without breaking the bank of collective society. The costs of healthcare have been increasingly problematic in recent years with so many issues surrounding the current system. With the “total health care spending in the United States expected to reach $4.8 trillion in 2021, up from $2.6 trillion in 2010 and $75 billion in 1970, meaning that health care spending will account for nearly 20 percent of gross domestic product (GDP), or one-fifth of the U.S. economy, by 2021” (Aetna). With this in mind it is apparent that as we look at the trillion-dollar industry of the medical community it seems that it needs to be a major focus of our nation as a whole and with the many issues come many creative solutions. First let us analyze the reasons behind the current cost and the major problems facing this industry and than discus what