Health Care Fraud

Today, health care fraud is everywhere the news. There undoubtedly is fraud in health care. an equivalent is true for each business or endeavor touched by human hands, e.g. banking, credit, insurance, politics, etc. there's no doubt that health care providers who abuse their position and our trust to steal are a drag . So are those from other professions who do an equivalent .

Why does health care fraud appear to urge the 'lions-share' of attention? Could it's that it's the right vehicle to drive agendas for divergent groups where taxpayers, health care consumers and health care providers are dupes during a health care fraud shell-game operated with 'sleight-of-hand' precision?

Take a better look and one finds this is often no game-of-chance. Taxpayers, consumers and providers always lose because the matter with health care fraud isn't just the fraud, but it's that our government and insurers use the fraud problem to further agendas while at an equivalent time fail to be accountable and take responsibility for a fraud problem they facilitate and permit to flourish.

1. Astronomical Cost Estimates

What better thanks to report on fraud then to tout fraud cost estimates, e.g.

- "Fraud perpetrated against both public and personal health plans costs between $72 and $220 billion annually, increasing the value of medical aid and insurance and undermining charitable trust in our health care system... it's not a secret that fraud represents one among the fastest growing and most expensive sorts of crime in America today... We pay these costs as taxpayers and thru higher insurance premiums... We must be proactive in combating health care fraud and abuse... We must also make sure that enforcement has the tools that it must deter, detect, and punish health care fraud." [Senator Ted Kaufman (D-DE), 10/28/09 press release]

- the overall Accounting Office (GAO) estimates that fraud in healthcare ranges from $60 billion to $600 billion per annum - or anywhere between 3% and 10% of the $2 trillion health care budget. [Health Care Finance News reports, 10/2/09] The GAO is that the investigative arm of Congress.

- The National Health Care Anti-Fraud Association (NHCAA) reports over $54 billion is stolen per annum in scams designed to stay us and our insurance companies with fraudulent and illegal medical charges. [NHCAA, web-site] NHCAA was created and is funded by insurance companies.

Unfortunately, the reliability of the purported estimates is dubious at the best . Insurers, state and federal agencies, et al. may gather fraud data associated with their own missions, where the type , quality and volume of knowledge compiled varies widely. David Hyman, professor of Law, University of Maryland, tells us that the widely-disseminated estimates of the incidence of health care fraud and abuse (assumed to be 10% of total spending) lacks any empirical foundation in the least , the small we do realize health care fraud and abuse is dwarfed by what we do not know and what we all know that's not so. [The Cato Journal, 3/22/02]

2. Health Care Standards

The laws & rules governing health care - vary from state to state and from payor to payor - are extensive and really confusing for providers et al. to know as they're written in legalese and not plain speak.

Providers use specific codes to report conditions treated (ICD-9) and services rendered (CPT-4 and HCPCS). These codes are used when seeking compensation from payors for services rendered to patients. Although created to universally apply to facilitate accurate reporting to reflect providers' services, many insurers instruct providers to report codes supported what the insurer's computer editing programs recognize - not on what the provider rendered. Further, practice building consultants instruct providers on what codes to report back to get paid - in some cases codes that don't accurately reflect the provider's service.

Consumers know what services they receive from their doctor or other provider but might not have a clue on what those billing codes or service descriptors mean on explanation of advantages received from insurers. This lack of understanding may end in consumers moving on without gaining clarification of what the codes mean, or may end in some believing they were improperly billed. The multitude of insurance plans available today, with varying levels of coverage, ad a wild card to the equation when services are denied for non-coverage - especially if it's Medicare that denotes non-covered services as not medically necessary.

3. Proactively addressing the health care fraud problem

The government and insurers do little or no to proactively address the matter with tangible activities which will end in detecting inappropriate claims before they're paid. Indeed, payors of health care claims proclaim to work a payment system supported trust that providers bill accurately for services rendered, as they will not review every claim before payment is formed because the reimbursement system would pack up .

They claim to use sophisticated computer programs to seem for errors and patterns in claims, have increased pre- and post-payment audits of selected providers to detect fraud, and have created consortiums and task forces consisting of law enforcers and insurance investigators to review the matter and share fraud information. However, this activity, for the foremost part, is handling activity after the claim is paid and has little pertaining to the proactive detection of fraud.

4. Exorcise health care fraud with the creation of latest laws

The government's reports on the fraud problem are published in earnest in conjunction with efforts to reform our health care system, and our experience shows us that it ultimately leads to the govt introducing and enacting new laws - presuming new laws will end in more fraud detected, investigated and prosecuted - without establishing how new laws will accomplish this more effectively than existing laws that weren't wont to their full potential.

With such efforts in 1996, we got the insurance Portability and Accountability Act (HIPAA). it had been enacted by Congress to deal with insurance portability and accountability for patient privacy and health care fraud and abuse. HIPAA purportedly was to equip federal law enforcers and prosecutors with the tools to attack fraud, and resulted within the creation of variety of latest health care fraud statutes, including: Health Care Fraud, Theft or Embezzlement in Health Care, Obstructing Criminal Investigation of Health Care, and False Statements concerning Health Care Fraud Matters.

In 2009, the Health Care Fraud Enforcement Act appeared on the scene. This act has recently been introduced by Congress with promises that it'll repose on fraud prevention efforts and strengthen the governments' capacity to research and prosecute waste, fraud and abuse in both government and personal insurance by sentencing increases; redefining health care fraud offense; improving whistleblower claims; creating common-sense psychological state requirement for health care fraud offenses; and increasing funding in federal antifraud spending.

Undoubtedly, law enforcers and prosecutors MUST have the tools to effectively do their jobs. 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 matter .

What's one person's fraud (insurer alleging medically unnecessary services) is another person's savior (provider administering tests to defend against potential lawsuits from legal sharks). Is tort reform an opportunity from those pushing for health care reform? Unfortunately, it's not! Support for legislation placing new and onerous requirements on providers within the name of fighting fraud, however, doesn't appear to be a drag .

If Congress really wants to use its legislative powers to form a difference on the fraud problem they need to think outside-the-box of what has already been wiped out some form or fashion. specialise in some front-end activity that deals with addressing the fraud before it happens. the subsequent are illustrative of steps that would be taken in an attempt to stem-the-tide on fraud and abuse:

- DEMAND all payors and providers, suppliers et al. only use approved coding systems, where the codes are clearly defined for ALL to understand and understand what the precise code means. Prohibit anyone from deviating from the defined meaning when reporting services rendered (providers, suppliers) and adjudicating claims for payment (payors and others). Make violations a strict liability issue.

- REQUIRE that each one submitted claims to public and personal insurers be signed or annotated in some fashion by the patient (or appropriate representative) affirming they received the reported and billed services. If such affirmation isn't present claim isn't paid. If the claim is later determined to be problematic investigators have the power to speak with both the provider and therefore the patient...

- REQUIRE that each one claims-handlers (especially if they need authority to pay claims), consultants retained by insurers to help on adjudicating claims, and fraud investigators be certified by a national accrediting company under the purview of the govt to exhibit that they need the requisite understanding for recognizing health care fraud, and therefore the knowledge to detect and investigate the fraud in health care claims. If such accreditation isn't obtained, then neither the worker nor the consultant would be permitted to the touch a health care claim or investigate suspected health care fraud.

- PROHIBIT public and personal payors from asserting fraud on claims previously paid where it's established that the payor knew or should have known the claim was improper and will not are paid. And, in those cases where fraud is established in paid claims any monies collected from providers and suppliers for overpayments be deposited into a national account to fund various fraud and abuse education schemes for consumers, insurers, law enforcers, prosecutors, legislators and others; fund front-line investigators for state health care regulatory boards to research fraud in their respective jurisdictions; also as funding other health care related activity.

- PROHIBIT insurers from raising premiums of policyholders supported estimates of the occurrence of fraud. Require insurers to determine a factual basis for purported losses attributed to fraud including showing tangible proof of their efforts to detect and investigate fraud, also as not paying fraudulent claims.

5. Insurers are victims of health care fraud

Insurers, as a daily course of business, offer reports on fraud to present themselves as victims of fraud by deviant providers and suppliers.

It is disingenuous for insurers to proclaim victim-status once they have the power to review claims before they're paid, but choose to not because it might impact the flow of the reimbursement system that's under-staffed. Further, for years, insurers have operated within a culture where fraudulent claims were just a neighborhood of the value of doing business. Then, because they were victims of the putative fraud, they pass these losses on to policyholders within the sort of higher premiums (despite the duty and skill to review claims before they're paid). Do your premiums still rise?

Insurers make plenty of cash , and under the cloak of fraud-fighting, are now keeping more of it by alleging fraud in claims to avoid paying legitimate claims, also as going after monies paid on claims for services performed a few years prior from providers too petrified to fight-back. Additionally, many insurers, believing a scarcity of responsiveness by law enforcers, file civil suits against providers and entities alleging fraud.

6. Increased investigations and prosecutions of health care fraud

Purportedly, the govt (and insurers) have assigned more people to research fraud, are conducting more investigations, and are prosecuting more fraud offenders.

With the rise within the numbers of investigators, it's not uncommon for law enforcers assigned to figure fraud cases to lack the knowledge and understanding for working these sorts of cases. it's also not uncommon that law enforcers from multiple agencies expend their investigative efforts and various man-hours by performing on an equivalent fraud case.