Types Of Fraud And The Healthcare Industry

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.

Health care fraud and abuse is a significant contributor to high health care spending, resulting in the wasteful spending of health care dollars. The Federal Bureau of Investigation (FBI) and National Health Care Anti-Fraud Association (NHCAA) estimates that 3 to 10 percent of health care dollars are lost to fraud and abuse (Federal Bureau of Investigation, 2010). Fraud is the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the deception could result in some unauthorized benefit to themselves or some other person (Ryan, 2006). Bloomberg reports health care expenditures are rising faster than the rate of inflation and spending in the US has nearly doubled in the last decade and one-half of health care

Id. In order for providers to avoid costly claim denials, a risk management and compliance program should be in place and annual monitoring and auditing of internal controls needs to occur on a regular basis. This text will review the issues that medical providers face with coding and billing regulations, the consequences of improper billing and coding, and resolutions that will aid in the prevention of claims being denied.

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

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

It is easy to see how fraudulent medical billing is having a major impact on the Unites States and the citizens of this country who rely on it on a daily basis. We often hear through the various new sources in this country, on the internet or out of the mouths of politicians and experts in the healthcare field about the failing healthcare system in this country. We often hear many different opinions on what needs to be done to fix our healthcare problem within this country and fix what looks to be a very broken system at this point. No matter what the solution to our poor healthcare system is one thing that is very clear is that healthcare fraud and abuse is playing a major role in the depletion of money in this country and the rise in healthcare costs for the citizens of this country.

Common fraudulent practices include billing for services never received, upcoding or unbundling of services, and mislabeling. Billing dishonest services occurs anytime a healthcare provider charges Medicare for a service the patient never received or billing for a more expensive service than performed. Upcoding and unbundling, two examples of billing for a more expensive service demonstrate this fraudulent practice. Simply put, upcoding occurs by billing more expensive codes than the services performed, while unbundling refers to a “bundled” service broken down or unbundled, allowing procedures billed separately to obtain a higher reimbursement than customary. Mislabeling, the practice of substituting non-covered services or products with services or products covered under Medicare guidelines also constitutes fraud. For example, a home healthcare company commits fraud by mislabeling house cleaning services, not covered by Medicare, as a nurse visit in order to receive payment. A pharmacy filling a patient’s prescription with generic drugs and charging for name brand drugs also represents mislabeling.

Perhaps the finest total dollar quantity of fraud is devoted via the medical health insurance companies themselves. There are severa research and articles detailing examples of insurance companies deliberately not paying claims and deleting them from their structures,[21] denying and cancelling coverage, and the blatant underpayment to hospitals and physicians beneath what are normal costs for care they provide.[22] Although tough to acquire the records, this fraud via coverage agencies may be anticipated through comparing revenues from premium bills and prices on health

The addition of the Affordable Care Act (ACA) has helped the CMS narrow down and shut down fraud. The government has new regulations of requirements for providers and what providers can participate under the ACA (Martin, 2015). There is additional screening for providers such as unscheduled visits, fingerprinting, background check, application fees, license checks, and most importantly they are now required face to face with patients before home health services. The government can suspend payments to providers under investigation. In addition, they can temporarily stop admission of new providers in the country when waste, fraud, and abuse are assumed

Like a regular business entity, healthcare facilities need continuous inflow of funds to continue existing. However, billing complexity in the health care industry is unlike all other industries. The biggest difference of healthcare from other businesses is the source of payment for services rendered: the majority of which is from a third party with pre-determined rates and strict prerequisites. Foundational to these prerequisites is the accuracy of medical coding. An interview with a coder provided fresh understanding of the coding profession. And a look into the private and government payers and insurers’ roles brings better

Healthcare Coding and Billing Standards of ethical coding are very important and should not be taken lightly. When guidelines are not followed it can lead to large fines and can even cause a healthcare organization to shut down. Making a mistake or willingly coding wrong can ruin the reputation throughout the community for healthcare. “Coding compliance is inherently linked to a number of the preceding compliance risk areas including proper documentation, accurate billing, medical records creation and retention, referral guidelines, and teaching physician rules. Acknowledging that one of the biggest areas of risk for health care providers is the accurate submission of claims and reimbursement to Medicare, an effective health care corporate compliance plan will also include an effective coding compliance plan (AAPC, 2009).”

Healthcare fraud and abuse in 2014 was costing Americans billions of dollars each year. Healthcare fraud intentions was to deceive a company into paying for services that in most case was not provided or should not been provided. Majority of the ones breaking the law are as follows physicians, patients,laboratories and some hospitals.

What is healthcare fraud? Healthcare fraud is a criminal behavior, in which a person files a false claim, with the purpose of reimbursement. Healthcare abuse is similar, but focuses more on practices that do not match up with accepted solid financial, business, or medical practices, thus resulting in an avoidable cost or repayment for services that are not needed, or that fail to meet professionally familiar values for healthcare (Johns Hopkins, n.d.). While these both may have very different definitions, they are fall under the category of healthcare fraud and are both punishable by law when convicted. Healthcare fraud may be something as simple as a doctor over billing the insurance for only a few dollars, all the way on up to

Health care fraud is defined as a type of white-collar crime that involves filing of dishonest health care claims in order to turn a profit. Healt Care Fraud,(http://www.law.cornell.edu/wex/healthcare_fraud) Fraudulent health care schemes come in many forms. False claims in billing, meaning they did a normal check up but billed your insurance company for procedures not done or labs never drawn. Lieing about performing a procedure but didn't do it but billed for it just to get paid. Another one is kickbacks and self referrals to gain financial benefits. Torts is defined as a civil wrong committed against a person or property, excluding breach of contract. An act, committed without just cause, may have caused physical injury, resulted in damage

Insurance companies and the federal government should pool resources using a percentage of profits to finance a task force to arrestively fight fraud. The penalty for fraud should be more stringent which will cause perpetrators to think twice before formulating a plan to commit fraud. The Affordable Health Care Act is the beginning of many programs established to fight against fraud. Health care fraud is a growing problem and should be taken more seriously by citizens of the United States. Physicians, health care workers, and patients are responsible for