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Health Care Fraud - The Perfect Storm
Health care fraud is everywhere in the news. There is definitely fraud in the field of health healthcare. This is the same for any business or venture handled by humans, e.g. banking, credit, insurance, politics, etc. There is no doubt that health care professionals who misuse their position and trust in order to profit are part of the major problem. Also, those in other professions that are guilty of similar things.

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What is the reason that health care fraud seem to receive the majority of media attention? It could be because it’s the best way to push agendas of divergent groups, where taxpayers, health consumers and health care professionals are all swindlers in a health fraud scheme that operates with’sleight-ofhand and a high degree of precision?

Have a look at it and you will see that this is not a chance to win. The taxpayer, the consumer and the provider always lose since the issue of health care fraud isn’t solely the fraud, it’s that our government and insurance companies exploit the problem of fraud to promote agendas and they fail to take accountability and on the liability for a fraud issue they allow to thrive.

  1. Astronomical Cost Estimates
    How better to present information on fraud than to announce the cost of fraud, e.g.
    — “Fraud perpetrated against both public and private health plans costs between $72 and $220 billion annually, increasing the cost of medical care and health insurance and undermining public trust in our health care system… It is no longer a secret that fraud represents one of the fastest growing and most costly forms of crime in America today… We pay these costs as taxpayers and through higher health insurance premiums… We must be proactive in combating health care fraud and abuse… We must also ensure that law enforcement has the tools that it needs to deter, detect, and punish health care fraud.” (Senator Ted Kaufman (D-DE), 10/28/09 press release].
    It is estimated that the General Accounting Office (GAO) estimates that the amount of fraud in healthcare can range from $60 billion to $600 billion annually which is anywhere between three percent and 10 percent from the total $2 trillion healthcare budget. Health Care Finance News reports 10/2/09] GAO is the investigatory branch of Congress. The National Health Care Anti-Fraud Association (NHCAA) estimates that over $54 billion in stolen funds every year from scams designed to get the insurance firms and us with deceitful and untrue medical expenses. NHCAA was founded and is supported by health insurance companies.

However, the validity of these estimates is a bit questionable at best. Insurance companies, federal and state agencies, as well as other organizations might collect data on fraud in connection with their respective tasks, and the amount quantity, quality and amount of information gathered varies. David Hyman, professor of Law at the University of Maryland, tells us that the widely circulated estimates of the frequency of health abuse and fraud (assumed at 10% the total expenditure) does not have any evidence-based basis whatsoever, and the information we know about fraud in the health sector and abuse is insignificant compared to the things we don’t know, and what we do know isn’t the case2. Health Care Standards

The laws and rules that govern health care - which vary between states and also from payer to payer They are a lot of information and can be difficult for providers and other to comprehend since the laws are written using legal jargon, not in plain language.

The providers use specific codes to document the conditions they treat (ICD-9) as well as services rendered (CPT-4 as well as HCPCS). These codes are employed to seek compensation from payers for the services provided to patients. Although they are designed to be universally applicable in order to ensure that accurate reports reflect the services of providers Many insurers require providers to report their codes that are based on what insurer’s editing programs can recognize rather than based on the service the provider actually provided. Furthermore, the practice building consultants provide providers with instructions on which codes to report to be paid. Sometimes, this means reporting codes that don’t accurately reflect the quality of the service rendered by the provider.

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The majority of consumers know the type of services they can expect from their physician or another service provider, but they may not know what the billing codes or descriptors for services are referring to when they explain the benefits provided by insurers. The lack of knowledge could lead to consumers moving along without knowing what the codes mean or could lead to some feeling that they were incorrectly charged. The variety of insurance plans that are available in the present, each with different degrees of coverage adds an extra dimension to the process when services are refused due to non-coverage , especially in the case of Medicare which defines non-covered services as not medically required.

  1. Be proactive in addressing the health insurance fraud issue
    The insurance companies and the government are unable to combat the issue through tangible actions that result in the detection of fraudulent claims prior to when they are even paid. Indeed, health claims claim to run a system of payment that is based on the assumption that providers will accurately bill for the services provided, since they cannot review each claim prior to making payment since the reimbursement system could be shut down.

They claim to employ sophisticated computer programs that look for patterns and mistakes in claims. They’ve also increased the preened post-payment checks of certain providers to identify fraud. They also have established task forces and coalitions comprised of law enforcement officers and insurance investigators who study the fraud issue and share information. But, this process is, in the majority of cases involves activities following the payment of a claim and is not a significant factor in the detection of fraud in the first place.

  1. Health care fraud is eliminated through the introduction of new laws
    The government’s annual reports on fraud are issued in combination with efforts to reform our health system, and our experience suggests that the end result is the government introducing and passing new laws, assuming that the new laws will lead to more fraud being detected and prosecuted, without knowing how the new laws will achieve this better than the existing laws that weren’t utilized in full.

Through these efforts in 1996 we received in 1996 the Health Insurance Portability and Accountability Act (HIPAA). The act was passed by Congress to deal with insurance portability as well as accountability for the privacy of patients and health fraud and abuse in the health care system. HIPAA was supposedly designed to arm federal law enforcement and prosecutors with tools needed to combat fraud and led to the development of a variety of new laws pertaining to health care fraud that include: Health Care Fraud, embezzlement or theft of Health Care, Obstructing Criminal Investigation of Health Care, and False Statements Concerning Health Care Fraud Matters.

In 2009 in 2009, it was in the year 2009 that the Health Care Fraud Enforcement Act was introduced in the year 2009. The law was recently presented by Congress with the assurance that it will enhance efforts to prevent fraud and increase the ability of the government to prosecute and investigate fraud, waste and abuse of both public and private health insurance through sendingencing increases; redefining the health care fraud as a crime and enhancing whistle-blower complaints as well as establishing a common-sense mental health requirements to prevent health-care fraud offences and increasing the amount of money allocated to the federal anti-fraud budget.

It is a given that law enforcement and prosecutors need the right tools to do their work. However, these actions alone, without inclusion of some tangible and significant before-the-claim-is-paid actions, will have little impact on reducing the occurrence of the problem.

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What’s one person’s scam (insurer claiming medically unnecessary services) is another person’s hero (provider conducting tests to protect against lawyers). Do you think tort reform is a viable option from those who advocate for health reform? It’s not! The support for legislation that places stricter and more stringent demands on service companies in the name of combating fraud isn’t a sign of an issue.