Life Insurance Fraud In The United States

One type of fraud is called fraud against other adults, specifically grandparent fraud. The scammer poses as their grandchild, close relative, or a representative (policeman or lawyer) of the relative, and tells them that they are in trouble, such as jail, and need money wired to them as soon as possible for hospital bills, jail bail, lawyer’s fees, etc. They tell the grandparent that they should not mention this

Fraud is a serious crime that should concern all parties of the U.S. health care system and is a costly reality that the government cannot overlook. While not all fraud can be prevented, by learning about the many different types of fraud, patients can be educated on how to protect themselves from fraud. If we use government programs to inform the public that they can be targeted, the dollar amount for these cases for fraud can be reduced. An informed public and a properly funded FBI will go a long ways in the overall crackdown of health care fraud.

In a scheme based in New Jersey and set to spread to eleven other states, Sheila Kahl, admitted to participating is a $1 Million Dollar Medicare fraud scheme. Along with her accomplice, Seth Rehfuss, convinced senior citizens to get genetic testic. The two fraudsters received commissions based off of the quantity of test that were ordered. To escalate matters, the two fraudsters used craigslist to locate healthcare providers that would work with them. Additionally, the two fraudsters also paid kickbacks to the healthcare providers that signed off on the testing for the senior citizens. (Pressofatlanticcity.com," n.d.)

In the case study, there has been fraudulent activity in this office that would warrant criminal sanctions. There have been claims filed in which patients were seen by an NP but billed as though they had seen a physician, at times, even when that physician was not in the office that day. This is a

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Physicians in several places have a bad reputation due to billing fraud. These acts are committed by individuals and organizations to proceed personal or business advantage. In fact, health care fraud is a type of crime that may be committed by health care providers or companies which provide medical supplies or services, and health care organizations. It is a recent trend to which physicians and their practices are unfortunately doing by organized crime groups in complex health care fraud schemes.

One of the main concerns in a fraud investigation is the analysis of facts and evidence. It is important to bear in mind that every fraud investigation is unique, as each fraud has its own set of facts and details. The investigator must be objective in her or his work and has to determine whether or not there is actually evidence of a fraud. Evidence of health care fraud includes patient medical records, computer files in processing the claims with Medicare, written or printed sources such as claim form, Medicare enrollment application, financial and billing data. It also includes testimony received from interviews of the witnesses or the patients themselves, bank records (personal and business account), and the explanation of benefits statement

Insurance Fraud is a felony. Claims are either false or exaggerated, and most times certain information are held back in order for the claimant to obtain the benefits that the insurance company has to offer and to avoid certain penalties. In this event, the claimant can be fined $150,000 or 10 years in prison. (Associated Content, 2007). It has been stated that at least %10 of all insurance claims has been fabricated and in North America the insurance industry pays out more than $30 billion in fraudulent claims. (Fraudcast, 2009) One of the most common insurance fraud would involve life insurance.

The process of the mail when it is sent out for delivery, the employee when dropping mail becomes aware of a bad address has to bring it back to their location and then gets processed to be return back to the original sender for a bad address.

In 2004, it was reported that healthcare had one hundred fifty billion dollars in losses due to health insurance fraud and abuse. Health insurance fraud and abuse can waste up to one-tenth of healthcare resources. Fraud and abuse also affects the consumer as it causes for the rise in premiums, less benefits, increase taxes and higher copayments. The occurring fraud and abuse also puts patients through unnecessary test and procedures for health insurance claims. Having an aggressive stance on preventing fraud by having a outsourced program established can help prevention in loss and harm to patients. Educating the organization on how much fraud can cost, and that patients are putting trust into the care they receive, expecting to not be deceived.

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Medical fraud and abuse is a huge contributing factor in the rise of healthcare costs in the United States. Although there are many definitions of fraud and abuse, according to Cigna and HIPPA, medical fraud is when there is false representation of a substance, device or a therapeutic system as a way of being beneficial in treating a medical condition, diagnosing a disease, or maintaining a state of health. Medical Abuse is defined ‘as any action that intentionally harms or injures another person’. It also involves actions that are inconsistent with accepted medical, business or fiscal practices. Abuse can directly or indirectly result in unnecessary costs to medical programs through improper payments. Insurance fraud occurs when companies and its agents intentionally misrepresent facts for financial gain.

Health care fraud is a serious crime that carries stiff penalties if you are convicted. Estimates show that fraudulent claims cost the government nearly 10 percent of the money disbursed toward health-related costs. Since the cost to handle fraudulent claims are so high, the federal government is cracking down on healthcare fraud and the courts are issuing stiff penalties. Healthcare fraud is not all-inclusive since there are several types of fraud.

I agree health care fraud is a major issue and determining how to handle that can be difficult especially because of HIPPA. When it comes to gaining information from health care industry many of these companies become extremely concern about violating patient’s person identity. As you stated having a fraud investigator take the lead during an investigation is a better approach to obtaining all the necessary information to better resolve the case.

Abstract— Fraud plays an important role in healthcare sector. It affects the whole system directly or indirectly. By increasing fraud in healthcare cost of treatments is also increased. It is calculable that some $700 billion is lost as a result of fraud, waste, and abuse within the USA healthcare system. Medicaid has been notably vulnerable target for fraud in recent years, with a distributed management model, restricted cross program communications, and a difficult-to-track patient population of low-income adults, their kids, and other people with certain disabilities. For effective fraud detection, one needs to cross-check the info on the far side the transaction-level.