The Common Types Of Fraud And Abuse

Healthcare fraud and abuse are substantial influence related to increasing health care cost. In the face of the seriousness of fraud and abuse offenses, increasing numbers of healthcare providers is pursuing new and more lucrative procedures to build business relationships. In the aspect of following an unsafe practice in order to receive kickback is uncalled for and serves as further investigation is necessary. OIG ‘s mission is to protect the integrity of the HHS programs and the health and welfare of the people

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

Fraud and abuse encompasses the actions of fraud, abuse, and waste in the health care system (McWay, 2014). It is a nationwide problem that affects all of us and can be committed by anyone. Schemes can be committed by a single person or a by an institution or group. The National Health Care Anti-Fraud Association (NHCAA) estimates that

Health insurance fraud is what drives up health insurance premium costs, wastes taxpayer’s money, but can also endanger beneficiaries or leave them uninsurable. In 2015, Medicare Strike Force reported over $700 million in false billing by doctors, nurses, other licenses medical professionals, laboratories, and individuals (FBI.gov). This is a staggering figure that is only getting worse. In this fictitious federal case I will be describing the criminal offender, the crime that was committed, the charge handed down by law enforcement, and the judicial process from the beginning of the criminal case to the sentencing of Dr. Richard Heartman, an internal medicine physician.

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.

As enforcement activities increase by the Department of Justice, though the above report of fraud and abuse was intentionally carried out over a seven-year period, it becomes clearer every day that even an unintentional billing mistake can lead to charges of fraudulent billing with severe penalties. In the end, the risks of not having an update to date and strong compliance program can potentially result in the damage financially to the specialty physicians practice and reputation can be substantial. It also requires

This booklet is designed to serve as a guidance to concepts of fraud and abuse laws which affect the coding, claims management, charge master and bill reconciliation. It is important to understand the laws as a variety of health care providers’ payment and arrangement activities are prone to fraud which eventually result in criminal penalties and unethical behaviors in health services. To evade associated liabilities, employees should understand the fraud and abuse laws and compliance policies.

Healthcare fraud and abuse is a significant hindrance in the United States that is having a negative impact on the individual as well the overall economy. Healthcare fraud and abuse costs the country billions of dollars every year, and ultimately has a vast, unfavorable impact on the quality and safety of healthcare. This is one reason I chose this topic. With the magnitude of fraud that is present, it actually angers me, and I hope to learn more about this subject. The losses accrued as a result from fraud and abuse results in higher costs on consumers, employers and taxpayers. Fraud and abuse can also result in serious harm to people who are subjected to unwarranted

Anyone in the medical field may seem trustworthy because most of the time they are. Unfortunately, there are those individuals who seek financial gain and are no longer trustworthy. There is no exact amount of how much fraud has been committed within the health care system, because it usually is never detected. Like in the case of Dr. Guerrero who committed a healthcare fraud scheme against his patients, employees of the health care system, and health care insurances. According to Vivek Pande and Will Maas, Dr. Guerrero was able to commit fraud against clients and the health care system and insurance providers; it is an ingenious crime, because the public considers them intelligent and high achieving individuals. (Pande & Maas, 2013) Overall, health care providers have a choice

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

In Relation to Health Care, Negligence is conducted under the “law of torts” in which involves unintentional harm that is inflicted onto patients which is caused by the carelessness of the health professionals in which these professionals are then held liable for the patient or client is injured (Forrester & Griffiths, 2015). From a health care professional’s perspective, this in other words mean that the professional is unable to provide quality standard of care that any other responsible and sensible individual would in similar situations. There are many different types of unfavourable events that are brought upon from the result of the negligence of health practitioners, including the administration of incorrect medication and doses, procedures

Clinical Programs strives to reduce unnecessary medical expenses and help improve quality of care by implementing innovative solutions to reduce Fraud, Waste and Abuse. Success is based on collaboration with key business partners and targeted initiatives that reduce pProvider abrasion and promotes evidence based medicine.

Patients come in with an idea of what the physician is supposed to do in certain cases and once their standards are not met, a malpractice suit ensues. The patient’s idea is defined by what their friends in the same situation have had done for them by health care providers with similar training and experience. These high standards set by patients will result in the patient paying tedious attention to any and everything a physician does in hopes of an opportunity to sue a physician. Sued physicians are more likely to stop seeing certain groups of patients which may include low income or elderly patients subjecting these patients not to have adequate access to competent and caring health care professionals.

In the world, Australia alone accounts for 80,000 medical negligence cases a year. This is mainly caused due to the doctor’s misinterpretation of the medical data (Medneg.com.au). Due to this, not only is the cost of diagnosis increasing but a study suggests that in 2008, 26% of indigenous people and 2.6% of general population in Australia had difficulty in accessing medical care due to the unavailability of

There are many different types of electronic fraud with which companies today must familiarize themselves. It is no longer sufficient to simply warn employees about clicking on suspect sites or to limit access to the company network. Hackers have become far more sophisticated in how they bypass industrial security and they are constantly altering their techniques to counter security and take advantage of new technology. The cyber terrorism that now exists is a threat not only to companies that harbor the data, but to every individual who may have their personal information saved by any company with whom they have dealt in the past. Serious steps must be taken to protect this information and, when necessary, punish those who may attempt to subvert the security currently in place.