Fraud In Health Care - The Perfect Storm by srilestari888

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									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!

								
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