Medical Identity Theft Case Study

When confidential patient information is disclosed without consent it is a violation of the HIPAA Title II Security Rule. This rule was enacted in response to private information being leaked to the news and emails containing privileged information were read by unauthorized people. Identity theft is a real concern so patient privacy should be taken seriously. This is a rule can easily be broken without the

In the health care business, there are certain standards and laws that have been put in place to protect our patients and their personal health information. When a health care facility fails to protect their patient’s confidential information, the US Government may get involved and facilities may be forced to pay huge sums of money in fines, and risk damaging their reputation.

Physician and pain clinic owner Paramjit Singh Ajrawat, of Potomac, Maryland has been ordered to

Fraudulent misrepresentation (fraud) is defined as the intentional deceit for personal gain (Clarkson, Miller, & Cross, 2012). Fraud occurs when a person knowingly represents an intentional deception as a fact to gain benefits they are not entitled. The boundaries between fraud and abuse seem to be confused; the degree of intent distinguishes fraud from abuse. Under HIPAA, it is considered a felony to intentionally implement a scheme to “defraud any health care benefit program or to obtain money or other property owned or controlled by a health care benefit program by means of false or fraudulent pretenses, representations, or promises” (Shepard, 2004, para. 1). Health care fraud is an intentional act to deceive in order to receive greater reimbursement for services, whereas health care abuse is conduct which is not consistent with acceptable

Attorney General Janet Reno indicated that health care fraud is the “number two crime problem in America following violent crime” (Reno, 1993). Health care fraud is a white-collar crime; but even more important, it contributes to an excessive loss of health care dollars. In 1949, Edwin Sutherland coined the phrase "white-collar crime". Sutherland defined the term as "crime committed by a person of respectability and high social status in the course of his occupation." White-collar crime encompasses a variety of non-violent crimes usually committed in commercial situations for financial gain. Many times considered “victimless” health care fraud is not without victims. Health care fraud and abuse affects federal programs and private sector insurers (Ryan, 2006). Fraud and abuse of federal health care programs and private insurers affect health care costs nationally, while

     On September 24, 2010, a laptop was stolen from an unlocked Urology office at the Henry Ford Health Systems hospital. The laptop did contain password protection software; however, it may not have been enough to permit access if the thief had advanced knowledge in computers. Additionally, the information stored on the laptop did not include social security or health insurance information, but instead held “patient names, medical record numbers, dates of birth, telephone numbers, e-mail addresses, and treatment and doctor visits” (Moscaritolo, 2010, p. 1). It is unknown how many records were contained on the laptop, but all records were related to prostate services that were provided during an eleven year span.

6. A breach of confidentiality can result in what consequences for a health care professional? The penalties for violating HIPAA range from civil penalties of up to $100 per person per incident for minor improper disclosures of health information, and up to $25,000 for multiple violations of the same standard in a calendar year. Federal criminal liability for improper disclosure of information or for obtaining information under false pretenses carries sanctions (fines) of $50,000 and one year in prison. The liability for obtaining protected health information under false pretenses with the intent to sell, transfer, or use the information for personal gain or for a malicious action, such as Medicare fraud, carries penalties of $250,000 and/or up to ten years in prison. Severe penalties are in effect if lax security allows health information to be stolen. There is also a risk of a class action suit as well as public relations damage to the institution’s or physician’s image.

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

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

This study sought to answer three research questions. Although the questions have been presented in previous chapters, they are worth presenting again.

Healthcare fraud is costly for everybody, as it harms the reputation of the institution or physician committing it, and financially damages the patient being affected.By definition fraud may be defined as intentionally employing surprise, trickery, cunning, deception and unfair ways by which one party cheats another party out of financial resources. In order to educate a healthcare manager regarding fraud , many aspects of fraud must be assessed. This includes the types of fraud, the consequences that come with fraud,the individual(s) committing them, techniques to prevent fraud, and why the healthcare industry is vulnerable to fraud.

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 department of Health and Human Services protects and guides the health and well being of individuals here in America (Thacker, 2014). They fulfill these duties providing Americans with adequate and efficient health and human services and monitoring services designed to increase the efficiency of care in the health system (Thacker, 2014). One of the services being monitored by the department of Health and Human Services is the electronic health record system, which carries private and vital information of patient’s health record enabling all eligible participating health workers access to these records (Thacker, 2014). A breach of the protective health information of patients in a health organization creates chaos as these are against the health insurance portability and accountability (HIPAA) law (Thacker, 2014). Hence, measure will have to be put in place to determine what caused the breach and how to rectify it to ensure the breach never happens again (Thacker, 2014).

     Imagine yourself lying on an operating table, motionless, quiet. Above, you notice people standing over you. You try to speak but the words just cannot come out. Your arms feel as if they are plastered to the table. You begin to stand up but feel as if weights are strapped to your back and you are bound to the table. Suddenly you feel a sharp pain in your midsection. In and out, you see a surgeon slicing your body open with a scalpel. Every motion the masked person makes is as if you are being torn apart from the inside out. One would hope this would simply be a nightmare and they will wake up and everything will be fine. In this instance, this person will