Today healthcare scam is all over the news. There are certainly healthcare fraud. The same is true for any business or company, touched by the hand of man, for example, banking, credit, insurance, politics, etc. There is no doubt that health care providers who are abusing their position and our confidence to fly a problem. So are other professions that do the same.
Why do I see the health care fraud for the "lion's share" of care? It could be that this is to drive the agendas of different groups the perfect vehicle where the taxpayer, healthcare consumers and healthcare providers are cheated in a shell game of fraud operated medical services just a trick "?
Take a look closer and found this is not a gamble. The taxpayers, consumers and suppliers are losing because the problem of care fraud health is not only cheating, but our government and insurers to other agendas, while in which to take the issue of fraud simultaneously accountable and responsible for the issue of fraud which facilitate and grow it.
1. Estimated astronomical costs
Is there a better way to report fraud and promote cost estimates of fraud, for example,
- "The fraud perpetrated against the two levels of public and private health costs between $ 72 and $ 220 billion per year, which increases the cost of health care and health insurance and public confidence decreases in our health care system ... it is no secret that fraud is one of the fastest growing and most costly forms of crime in America today ... these costs to be paid as a taxpayer and premiums "higher health insurance. .. We must be proactive in the fight against fraud and abuse of health ... we must also ensure that law enforcement has the tools it needs to deter, detect and punish health care fraud. "[Senator Ted Kaufman (D-dE), 10.28.09 Press Release]
- The General Accounting Office (GAO) estimates that healthcare fraud in the range of $ 60 billion to $ 600 billion a year - or somewhere between 3% and 10% of the health budget of $ 2 billionth [Healthcare Finance News reported, 02:10. 09] the GAO is the investigative arm of Congress.
- The National Association for the Fight Health Fraud (NHCAA) reported more than $ 54 billion annually develops in fraud for us and our insurance companies, are stolen to continue the fraudulent and illegal medical costs. [NHCAA, side] was created NHCAA and is financed by the health insurance.
Unfortunately, the reliability of estimates of assumptions is suspect at best. The insurer, state and federal authorities and other data from fraud to collect their own missions, where the nature, quality and quantity of data collected varies greatly. David Hyman, a professor of law at the University of Maryland, said that the estimates largely the impact of widespread fraud and abuse in health care (10% of total expenditure assumes) is without any empirical basis at all, they know very little about the health fraud and abuse by the shadow is what we know and what we know, it is not. [The Cato Journal, 3/22/02]
Health care standards. 2
The laws and regulations governing health care - vary from one state to another, and are payable by the payer - are large and very confusing to suppliers and others to understand how it is written in legalese and said nothing.
use provider to display certain codes of the condition treated (ICD-9) and services (CPT-4 and HCPCS). These codes are used in the search for a compensation to be paid for services provided to patients. Although it was created to provide universally apply accurate information to obtain service providers report many insurance companies codes suppliers on the basis of what computer programs recognized the mandate insurers editing - not in the condition that the supplier. Moreover, it has the practical design consultants suppliers to report the code to get the payment - in some cases, codes that accurately can not refer to the service provider.
Consumers know what services they receive is from your doctor or another provider, but may have no idea what these billing codes or service descriptors mean get the benefits of insurers to explain. This lack of understanding can lead to spending consumers without clarifying the meaning of the code, or may cause some were calculated incorrectly believe. The variety of insurance plans available today, with various levels of coverage, announces a wild card in the equation when they are denied services for lack of funds - especially if they are not treated to refer Medicare Services is are not medically necessary is ,
3. Address the issue of fraud Proactive healthcare
do the government and insurers little to proactively solve the problem with concrete activities that will lead to the detection of inappropriate statements before they are paid. In fact, payers of healthcare proclaim claims on the basis of trust that the law offered to operate accurately for services because they do not all claims prior to payment of the payment system, because the system can check closed refund.
They claim, sophisticated computer programs for errors and patterns in the claims are used, increased before postpaid fraud vendor capture selected and audits, created composed consortia and working groups of law enforcement agencies and to study insurance investigators the issue of exchange of information and fraud. However, this activity was focused primarily on the business after the claim paid and has little to do with proactive detection of fraud.
4. Exorcise healthcare fraud by creating new laws
The government reports on the issue of fraud are serious in connection with the efforts published our health care system reform and our experience shows that the results in the Government the introduction and adoption of new laws - new laws are adopted, discovered by more fraud, investigated and prosecuted lead - without noting that new laws that make it better than the existing laws are not being used to its full potential.
With these efforts in 1996, we Accountability Act (HIPAA) and Health Insurance Portability. It was passed by Congress in response to the portability of insurance and the responsibility of the private life of patients and health care fraud and abuse. HIPAA should provide forces and prosecutors available, the tools to combat fraud and led to the creation of a number of laws fraud health care, including: healthcare fraud, theft or embezzlement health services, obstruction of health care and making false statements instances of health care fraud.
In 2009, the Law Enforcement fraud appeared to healthcare on the scene. This Act was recently introduced by the Congress with the promise that they relate to fraud prevention activities and the ability of governments to strengthen in order to investigate waste fraud and abuse in government and insurance, and to pursue a private health insurance to increase by the set; Redefining the crime of care fraud health; improve the plaintiffs' claims; Establish conditions sense of the mental state of health care fraud crimes; and an increase in resources to fight the federal spending fraud.
Certainly should the law enforcement agencies and prosecutors have the tools to do their job effectively. However, these measures alone, to be paid without the inclusion of certain tangible and important measures required, will have little impact on reducing the occurrence of the problem.
What is the fraud of a person (insurer claiming medically necessary services) El Salvador is another (test management vendors to do with possible prosecution sharks). Reform of the tort is a possibility that health care reform advocate? Unfortunately, there is not! Support for the legislative requirements and new expensive providers on behalf of the fight against fraud imposed, however, seems to be no problem.
If really want to Congress as part of the legislative power to make a difference to the problem of fraud, for you to think outside the box, what has been done in some form or fashion. Focus on a background activity, which aims to combat fraud from it before it happens. Below are examples of measures that could be taken in an effort to curb fraud and abuse of flood stop:
Make allowed all payers and providers, suppliers and others just use coding systems if the codes clearly determined so that each can know and understand what the specific code -. No person is different from the concept defined service reports (providers, suppliers) and the loss of entitlements (and other payers). Make violations a matter of strict liability.
- Request that all applications submitted to public and private insurers in any way signed by the patient commented (or appropriate official), which indicates that the services received and invoiced informed. was, if such a declaration is not this claim is not paid. If the application is later found that the problems that researchers have the opportunity to talk to providers and patients ...
Require all managers (especially if they have the power to pay claims), presented advisor by insurers to help the certified by a national company deciding on applications and fraud investigators, for certification under the jurisdiction - Government suspend that they have the necessary knowledge for the recognition of healthcare fraud, and to capture the knowledge and investigate healthcare fraud claims. If such certification is not obtained, neither the workers nor the consultants would be allowed to touch a need for medical care or health care investigate suspected fraud.
Prohibit public and private payers, the claims of fraud previously paid is to be asserted if the defendant knew or should should know the request was inappropriate and should not have been paid -. are established and in cases where fraud paid in claims arising from collected for overpayments from providers and suppliers are stored in a national account to consumers various programs of fraud and abuse to finance training, insurance companies, law enforcement agencies, prosecutors, legislators and others ; finance to investigate the best researchers of supervisors on health care in the state fraud in the respective countries; and resources for other health services activities.
- To increase Prohibit insurers premiums the policyholder is based on estimates of fraud. Require insurers an objective basis of the losses in the alleged fraud and showing tangible proof of their efforts due establish detect fraud and to investigate and not to pay fraudulent claims.
5. Insurers are victims of health care fraud
Insurers, as a normal course of business provide reports of fraud as a victim of fraud by devious vendors and suppliers presented.
It's bad for the insurer to announce the status of victim, if they have the opportunity to review the applications before they are paid, but not to vote, because it will interfere with the flow of the refund system, which is understaffed. Moreover, for years have operated in a culture in fraudulent claims, insurers, were only part of the cost of doing business. Then, because (despite the commitment and the ability to check requests before they are paid). Victims of fraud alleged, these losses to policyholders in the form of higher premiums over Your premiums continue to rise?
Insurers earn a lot of money, and under the guise of the fight against fraud, keep him in the claims alleged fraud over after the money in claims for services paid for legitimate claims and are not going to pay for many years before the supplier to petrified fight Has. many insurance companies, arguing that the lack of response of the security forces, civil actions against suppliers and organizations addition assert in the fraud.
6. fraud investigations and prosecutions of increased health care
It is alleged that the government (and insurance) concerned to examine fraud and more people, to carry out further investigations and prosecute more offenders are scams.
With the increasing number of researchers, it is not uncommon for law enforcement agencies assigned scam to work, the lack of knowledge and work to understand these types of cases. It is not uncommon for law enforcement agencies several research efforts and spend countless hours on the same case of fraud to work.
The police who are not actively investigate, especially at the federal level of fraud, if they have the tacit approval of a prosecutor. Some law enforcement wants to work any circumstances, no matter how well represented in search of a control to a decrease in cases in the most negative light.
Health counseling regulators are often not seen as a viable member of the research team. Together to investigate complaints about misconduct by dealers of their skills regularly. The consistency of these plates are suppliers, usually active in practice, they have the pulse of what is happening in your state license.
The insurer, at the urging of Insurance Supervisors in the state, has created with suspicious applications to treat special investigation units to facilitate the payment of legitimate claims. Many insurance companies have lawyers earlier recruited forces of health without research experience to understand the little or no care related experience and / or nurses of these units.
Trust is essential prior to the establishment of fraud and often an important tool for law enforcement and the prosecution in cases of fraud obstacle. The function refers to payers who rely on the information from the suppliers get an accurate representation of what was expected in their determination to pay claims. there are problems of fraud in the supplier misrepresent material facts of complaints, such services are not provided, the service provider denaturation etc.
The increase in fraud recoveries and financial procedures? In several countries (federal) continues in the United States there are different thresholds deficit should never before (illegal) processing activity, for example, $ 200,000.00, $ 1,000,000 are considered overcome. What this says fraudsters - pull up to a certain amount, to stop and change the dishes?
Ultimately, healthcare is fraud Shell game perfectly to avoid paying for caregivers of the band and away and competing suppliers unrestricted access to the system supply of dollars to be able or not, they are prepared to use the mechanisms necessary health properly fraud - in front end before claims are paid! This sneaky suppliers know that each application has not been respected, before you pay, then knowing work that it is impossible to detect, investigate and prosecute those who commit fraud!
Fortunately for us, there are a number of experienced and dedicated professionals who insist in the trenches against fraud work struggling in distress, make a difference of a complaint / case at a time! These professionals include but are not limited to: all disciplines offered; Supervisors (insurance and health care); Casualty Insurance Company Manager and special investigators; Local forces, national and application of federal law; Federal and prosecutors; and other.
