Fraud In Health Care - The Perfect Storm Today, health care fraud is everywhere in the news. It is likely that fraud in health care. The same is true for each trade or business affected by human hands, banking, credit, insurance, politics, etc. There is no question that doctors who abuse their position and our confidence to fly are a problem. So are other professions that do the same. Why fraud in the health care seems to have the lion's share "of care? Is the ideal vehicle to carry out programs for the groups differed on taxpayers, consumers care providers health and wellness are deceived by the fraud in the shell game the health care work with the phrase "sleight of hand"? Look closer and you'll see it's not a game of chance. Taxpayers, consumers and suppliers always lose, because the problem of health care fraud not only fraud, but it is our government and insurance companies use fraud problem to other agendas, while failing to account and take the responsibility of a fraud problem, they facilitate and allow it to flourish. First astronomical cost estimates What better way to report fraud and then brag about the estimated costs of fraud, such - "The fraud on the public and private health plans cost between $ 72 and $ 220 billion a year, which increases the cost of medical care and health insurance, and weakens public confidence in our healthcare system not ... longer a secret that fraud is one of Finland's fastest growing and most expensive crime in America today ... We will pay these expenses as taxpayers, and increase the premiums of health insurance ... we must be proactive in fighting healthcare fraud and abuse ... We must also ensure that law enforcement has the tools necessary to deter, detect and punish health care fraud. "[Senator Ted Kaufman (D-DE), 10.28.09 Press print] - The General Accounting Office (GAO) estimates that fraud in the ranges of health care of $ 60 billion to $ 600 billion a year - or anywhere between 3% and 10% of the budget of $ 2 trillion health care. [Reports on Health Finance News, 02/10/09] The GAO is the investigative arm of Congress. - National Health Care Anti-Fraud Association (NHCA) reported more than $ 54 billion are stolen every year in scams designed to unite us and our insurance fraud and medical expenses. [NHCA, website] NHCA was created and is funded by health insurance companies. Unfortunately, the reliability of estimates of the alleged dubious at best. Insurance companies, state and federal agencies, and others can gather information about their fraud activities, with the species, and the amount of data collected varies greatly. David Hyman, professor of law at the University of Maryland, tells us that the estimates are widely distributed in the prevalence of health care fraud and abuse (assumed to be equal to 10% of total expenditure) lacks an empirical basis to all, what little we know about the health of abuse is dwarfed by what we know and what we know is not so. [Cato Journal, 3/22/02] Second health care standards Laws and regulations governing health - vary from state to state and pays the debtor - are vast and confusing to providers and others to understand how they are written in legalese, and not speak out. Suppliers use special codes to the report relates to the conditions (ICD-9) and services (CPT-4 and HCPCS). These codes are used when seeking compensation from the payers of services to patients. Although designed to apply universally to facilitate accurate reporting to reflect the service providers, "many insurers instruct providers to report codes based on what programs the insurer publishing computer to recognize - and not Does the provider rendering. In addition, consultants building practice instructions on what providers to report codes to get paid - in some cases, codes that do not accurately reflect the service provider. Consumers know what services they receive from their physician or other supplier, but can not get an idea of what they are billing codes or descriptors of service means the explanation of benefits received by insurers. This lack of understanding can lead consumers to graduate without clarification of what the codes mean or might lead to some belief that they have been incorrectly charged. Many insurance policies available today, with different levels of coverage to a wild card into the equation when services are denied to non-coverage - especially if it is Medicare, which denotes non-covered services are not medically necessary. 3. Proactively address the problem of healthcare fraud The government and insurance companies do little to proactively address the problem of physical activities that will result in the detection of inappropriate requirements before they are paid. In fact, payers of health care requires claim to operate a payment system based on trust that the service providers of Bill precisely because they can not review each application before payment is made because the compensation system would be arrested. They claim to use sophisticated computer programs to check for errors and patterns of demand, increased pre-and post-payment audits of selected suppliers to detect fraud, and created consortia and labor force composed of law enforcement and insurance investigators to examine the problem and share information on fraud. But this activity, mainly with the activity after the claim is paid and has little influence on the proactive detection of fraud. 4. Summon health care fraud, new laws Government reports on the problem of fraud was released for good in the context of efforts to reform our health care system and our experience shows us that ultimately results in the government to introduce and adopt new laws - the presumption of new laws will lead to more fraud detection, investigation and prosecution - without defining how new laws will make this more effective than the existing laws were not used to their full potential. With such an effort in 1996, we received the Health Insurance Portability and Accountability Act (HIPAA). It was adopted by Congress to resolve the insurance portability and accountability of patient privacy and fraud and abuse in health care. HIPAA was to equip law enforcement and federal prosecutors the tools to tackle fraud and resulted in the creation of a new law on health care fraud, including: Healthcare Fraud , theft or misappropriation of funds in health, hindrance to the criminal investigation of health care and making false statements on issues of fraud Healthcare. In 2009, the Health Fraud Enforcement Act emerged. This tool was recently introduced in Congress, promising to build anti-fraud efforts, and increase the capacity of governments to investigate and prosecute waste, fraud and abuse, as well as government and private health insurance, a judge more, a redefinition of healthcare fraud, crime, improving whistleblower claims, creating a common sense requirement of the state mental health care fraud, and increase funding for federal anti-fraud agency fees. Undoubtedly, law enforcement and prosecutorial authorities must have effective tools to do their job. These actions alone, without some tangible and important first - a requirement-is-paid work, has little effect on reducing the occurrence of the problem. What a fraud of a person (the insurance company that is medically unnecessary services) is the savior of another person (the supplier of test execution to defend all causes by sharks legal). It's tort reform, the opportunity to lead health care reform? Unfortunately, it is not! Support for the legislation placed new demands on service providers and heavy to fight fraud in the name does not appear to be a problem. If Congress really wants to use its legislative powers to make a difference in the problem of fraud they need to think outside-the-box, which is already in some form or fashion. Focus on a frontal activity which deals with the settlement of fraud before it happens. The following are examples of actions that can be taken to try to stem the tide of fraud, and abuse: - Require all payers and providers, suppliers and other code systems use only approved when the codes are clear for all to know and understand what the specific code. Do not allow anyone to deviate from the defined meaning in the service statement (suppliers, subcontractors) and essential requirement for the payment (accounts receivable and other). Questions makes violations of strict liability. - Require that all requests for public and private insurers are signed or marked in some way by the patient (or appropriate representative), claiming they had been informed services and charges. If this statement is not this claim is not paid. If the claim is later determined that the problem researchers the ability to speak with the provider and the patient ... - Require that all operators certificates (especially if they have the authority, salary), consultants to keep the insurance companies to assist the claims contracting, fraud investigators and certified by a company of national accreditation under the jurisdiction of the Government shows, who have the knowledge needed to recognize health fraud, and the data reveals, and to investigate health care fraud. If such approval is not obtained, as an employee or consultant can not touch the alleged or suspected health care fraud, health care. - Prohibits public and private payers to submit fraudulent claims previously paid, if it is found that the recipient knew or should have known of the alleged improper and should not pay. And in cases where fraud is established in claims paid in money collected and deposited in excess of journalists for national account to finance a series of fraud and abuse training programs for consumers, insurers, legislators, prosecutors, legislators and others, the fund researchers at the forefront of health regulatory boards on fraud investigations on their own jurisdiction, as well as the financing of health related activities. - Prohibit insurers from increasing premiums for the insured based on estimates of the incidence of fraud. Require insurance companies to establish a factual basis for the alleged loss due to fraud combined to show tangible evidence of their efforts to detect and investigate fraud and not paying fraudulent claims. 5. Insurers are victims of fraud in the healthcare Insurers, as a normal course of business, provides reports of fraud to appear as victims of fraud by providers and suppliers aberrant. It is hypocritical on the part of insurers to proclaim the status of victim when they have the ability to review applications before they are paid, but chose not to because it would affect the flow of the compensation which is insufficient. In addition, this year, insurance companies have operated in a culture in which fraudulent claims were just part of the cost of doing business. So because they were victims of the alleged fraud, they pass these losses to policyholders in the form of higher premiums (in spite of the obligation and the ability to review applications before they be paid). Make your premiums continue to rise? Insurers are a lot of money, under the pretext of the fight against fraud, are keeping more of him, alleging fraud in the claims to avoid paying legitimate claims and amounts paid after going to claims for services provided for many years before suppliers are also petrified to answer. In addition, many insurance companies, the belief in a lack of response from law enforcement, file civil suits against providers and entities alleging fraud. 6th Increase investigation and prosecution of health fraud Allegedly, the government (and insurance) is attributed to several people to investigate fraud, carries a number of studies, and they are to prosecute violators of fraud. With the increasing number of investigators, it is not uncommon for police officers assigned to fraud cases that lack of knowledge and understanding to the work of these types of cases. It is not uncommon for law enforcement agencies use a number of investigative efforts and many man-hours by working on the same fraud case. Lawmakers, especially at the federal level, can not be active in the search for fraud, unless it were to accept the charge. Some of the legislators who do not want to work, in the case, no matter how well you can find the prosecutor declination cases presented in a negative light. Health regulations of the Forum is not often seen as a viable member of the investigative team. Councils regularly investigate complaints of inappropriate conduct of licensees under their responsibility. The main result of this advice is authorized providers, usually in active practice who has the pulse of what's happening in their state. Insurers, on the insistence of state insurance regulators established special investigative units to deal with suspicious claims in order to facilitate the payment of legitimate claims. Many insurers have hired responsible for enforcing the law with little or no previous experience in health care and / or nurses who have no experience of research to establish these units. Reliance is crucial for the establishment of fraud, and often a major obstacle for law enforcement and prosecutors on the movement of fraud before. Reliance refers to paying based on information providers to be an accurate representation of what was stated in their willingness to pay claims. Problems arise when providers misrepresent material fraud in the claims, these services not rendered, to pursue their own service provider, etc. Increase in prosecutions for fraud and financial recovery? Proceedings in different jurisdictions (federal) in the United States, there are different loss thresholds must be exceeded before the activity (illegal) will be considered for prosecution, for example, $ 200,000.00, $ 1 million. What the scammers - fly to a certain amount of stopping and changing jurisdictions? Ultimately, health care fraud shell game is perfect for caregivers and providers diverted the strip and vendors jockey for free access to health care payment in dollars can not or will not use the mechanisms necessary to adequately address the fraud - the front-end before the claims are paid! These providers and suppliers know that diverted each claim does just before you pay for and operate in the knowledge that it is impossible to detect, investigate and prosecute anyone who commits fraud!
Pages to are hidden for
"Fraud In Health Care - The Perfect Storm"Please download to view full document