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Posted: May 5th, 2020
The healthcare sector is faced with several types of fraud which lead to the loss of huge sums of money that end up in the pockets of fraudsters. Health care fraud includes swindling of money in insurance firms or medical programs such as Medicare in the United States of America. It also includes corruption in the provision of medical care and drugs. Quackery is a type of fraud whereby fake doctors pretend to be qualified medical professionals who can provide health care services to patients.
In the United States, any medical professional found guilty of health care fraud face punishments such as incarceration, fines and even losing their license. The Federal Bureau of Investigations, Inspector General and U.S postal service do investigations on matters of health care fraud. Whistleblowers who identify and report cases to the authorities are rewarded.
There are various schemes used to defraud the health care system. These include; billing for services not rendered, upcoding services and medical equipment, duplicate claims, kickbacks, unnecessary services, excess services and unbundling. Billing for services not rendered includes charging Medicare for services that were not offered and forging signatures of those working in Medicare.
Upcoding service is a situation whereby a pharmaceutical firm or hospital offers bills to Medicare for services that were rendered but the price surpasses the actual price. Upcoding medical items include presenting bills of medical equipment that exceeds the actual, for instance, the list may include a power-assisted wheelchair but only a manual wheelchair was offered to the patient.
Excessive services include adding extra services on the list. Hospital managers sometimes conduct surgeries that are not required or produce bills with extra items that are not needed and later sell them to the black market. Unnecessary service is a situation where a medical professional present a bill to Medicare of services and equipment that are not necessary, for instance, if a patient is suffering from acne, painkillers are not necessary unless the patient is in pain.
Duplicate claims include changing dates and sending bills of the same goods and services twice. Unbundling is presenting the bills of various medical items and services separately so that they can cost higher, putting them together lowers the total price. Kickback is offering gifts and vacations to medical professionals so that they can allow the use of certain medical services. It is challenging to highlight the amount of money lost in health care frauds as some of the cases go unnoticed.
Sparrow, Malcolm K. License to steal: Why fraud plagues America’s health care system. Boulder, CO: Westview Press, 1996.
Kalb, Paul E. “Health care fraud and abuse.” JAMA 282.12 (1999): 1163-1168.
Li, Jing, et al. “A survey on statistical methods for health care fraud detection.” Health care management science 11.3 (2008): 275-287.
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