Today, health care fraud is all over the news. There certainly is fraud in health care. The same is true for all companies or effort untouched by human hands, such as banking, credit, insurance, politics, etc. There is no doubt that doctors who abuse their position and our confidence to steal a problem. The same is true with other professions that do the same. Why health care fraud appear to have the ‘lions share’ of attention? Could it be that is the perfect vehicle to drive divergent group programs where taxpayers, consumers and health care providers are duplicated on a health care fraud cover-operated precision game “handshakes”? Take a closer look and found this is not a game-of-opportunity plantar warts.
Taxpayers, consumers and suppliers always lose because the problem of health care fraud is not only fraud, but is that our government and insurers use the issue of fraud on the agendas of others, while at the same time, while remaining accountable and take responsibility for facilitating a fraud problem and allowed to flourish. 1. The astronomical cost estimates What better way to report fraud then to promote the cost estimates of fraud, for example, – “The fraud perpetrated on public health and private plans cost between $ 72 and $ 220 billion per year, increasing the cost of medical care and health insurance and undermine public confidence in our health care system. .. It’s not a secret that fraud is one of the fastest growing forms and more costly crime in America today … we have to pay these costs to the taxpayer and through higher health insurance premiums Be proactive … in the fight against fraud and abuse of health … We must also ensure that law enforcement has the tools you need to deter, detect and punish health care fraud. ” [Sen. Ted Kaufman (D-DE), press release 10/28/09] – The General Accounting Office (GAO) estimates that fraud in health ranges from $ 60 billion to $ 600 billion per year – or anywhere between 3% and 10% of health budget $ 2000 billion care. Health Care [News reports of Finance, 10/2/09] The GAO is the investigative arm of Congress. – The national health system of the Anti-Fraud Association (NHCAA) reports more than $ 54 billion is stolen each year in scams designed to stick to us and our medical insurance companies and illegal fraudulent charges. [NHCAA, website] NHCAA was created and is funded by health insurance companies. Unfortunately, the reliability of estimates is questionable assumptions. Insurers, state and federal agencies, and others may collect data for fraud related to their own missions, where the kind, quality and volume of data collected is highly variable. David Hyman, professor of law at the University of Maryland, says that the widely reported estimates of the incidence of health care fraud and abuse (which accounts for 10% of total expenditure) lacks any empirical foundation at all, little they know about the fraud of health care and abuse is dwarfed by what we know and what we know not.
2. Health Care Standards The laws and rules governing health care vary from state to state and payer paying – are spacious and very confusing for providers and others to understand how they are written in legalese, not to speak out. Providers use specific codes to report the conditions treated (ICD-9) and services (CPT-4 and HCPCS). These codes are used in seeking compensation from payers for services rendered to patients. Although it was created to apply universally to provide accurate information to reflect the services of suppliers, many insurers instruct providers to report on the basis of the codes of the programs the computer insurance edition of recognizing – not in provided that the provider.
In addition, consultants from the practice of creating instruct suppliers on what the report codes to receive payment – in some cases the codes do not accurately reflect the service provider. Consumers know what services they receive from your doctor or other provider, but can not get an idea of what billing codes or service descriptors refer to the explanation of benefits received from insurers.
This lack of understanding can lead consumers to move without a win in the clarification of what the codes, or may result in some believe they were billed correctly. The multitude of insurance plans available today, with different levels of coverage, ad a wildcard for the equation when services are denied for lack of coverage – especially if it denotes Medicare noncovered services that are not medically necessary . 3. Proactively address the health care fraud problem The government and insurance companies do little to proactively address the problem with the specific activities that will result in the detection of inappropriate statements before they are paid.
In fact, claims payers of health care claim to operate a payment system based on trust that providers bill accurately for services rendered, as we can not review every claim before payment is made by the reimbursement system would be disrupted. They say they use sophisticated computer programs to find errors and patterns in complaints have increased pre-and post-payment audits of selected providers to detect fraud, and created consortia and working groups composed of agents of law and insurance investigators to study the problem of fraud and share information. However, this activity, for the most part, it is the activity after the claim is paid and has little influence on proactive detection of fraud.
4. Exorcise the health care fraud through the creation of new laws Government reports on the issue of fraud seriously are published in conjunction with efforts to reform our health care system, and our experience shows us that ultimately results in the government of the introduction and enactment of new laws – which assume the new laws will result in more fraud detected, investigated and tried – without establishing how new laws to accomplish this more effectively than existing laws were not used to its full potential. With these activities in 1996, we had the Health Insurance Portability and Accountability Act (HIPAA)
. It was enacted by Congress to address insurance portability and accountability of patient privacy and health care fraud and abuse.
HIPAA was supposed to provide enforcement and federal prosecutors with the tools to attack fraud and led to the creation of a series of new statutes for health care fraud, including: Health Care Fraud, theft or misappropriation of funds in Health Care, obstruction of Criminal Investigation of Health Care and false statements concerning care fraud issues plantar warts review.