This website uses cookies to ensure you have the best experience. Learn more

Fraud And Abuse In The Healthcare System

932 words - 4 pages

Healthcare services have been on the rise for over 10 years now. According to a 2012 consumer alert, the industry provided $2.26 trillion in payments for more than four billion health insurance benefit claims in the year 2011(Fraud in Health Care). The bulk of the claims and the mainstream of fraud and abuse stem from the Medicare system professionals, who are knowledgeable about the process and persuade new clients into handing over their pertinent information in hopes of deception and illegitimate claims. Multiple and double billing, fraudulent prescriptions, are some of the major flaws in this organization that has made the healthcare services industry curdle. (AGHAEGBUNA, 2011) This is a non-violet crime and is often committed by very educated people including business people, hospital, doctors, and administrators.
Multiple billing
There are numerous amounts of billing codes within the Medicare system. Many have the same codes to one medical piece of equipment. If a biller tries to make a claim for a device, such as a wheelchair and walker, and the claim was denied based on excessive usage of that particular code because of its geographic region, then the biller can easily resubmit the claim using an alternative code that will allow the claim to go through with minor alternations to the device (AGHAEGBNO, 2001). The biller can complete this task several times until the claim is satisfied. The biller can also bill for services that were not provided in order to receive higher payments from health care providers. These are forms of multiple, double and improper billing abuses that are defrauding the system tremendously. Health care claims are coming in quickly and some payments are even expedited and reused to medical providers. This is a problem because claims are not being reviewed which in return fraudulent claims are going through undetected. Employees who have access to ERH modules and billing modules in a provider entity could be able to enter fraudulent encounters, generate billing, and then delete documented encounter data. (Fraud in Health Care) 2010.

Forged prescriptions
Fraudulent prescriptions are also on the rise. Physicians are writing illegal prescriptions that are billed for a claim for reimbursement, but have yet to see a bill of rendered services that called for the actual prescription. This often ends up happening to a patient who has little or no medical issues and has never been seen before. The provider who receives the forged prescription profits an anticipated amount of 15% to $20% in profits. (AGHAEGBUNA ,2011). There are four types of fraud that healthcare providers’ organization face. Patient fraud, provider employee fraud, provider billing fraud and payer fraud, even though providers need to receive payment for their service they should be more preventative action in place to ensure that these fraudulent activities can be detected.
Fighting Fraud
According to the new law the OIG’s effectiveness will be...

Find Another Essay On Fraud and Abuse in the Healthcare System

Genetic Testing and the US Healthcare System

2442 words - 10 pages treat illnesses but we continue to use them excessively. As a result, we must find a way to reduce our use of such technologies and therefore reduce our overall health care expenditures. If we do not, healthcare costs will rise to $2.18 trillion by 2008. Therefore, the answer to reducing costs is to adopt a healthcare system based upon preventive medicine. With the rapid advances in medical science in the past half century, the healthcare

Mental Health Stigma and the Healthcare System

2576 words - 10 pages to place themselves into a good job or a suitable place to live (Corrigan). There are many reasons why one may choose to discriminate against the mentally ill. It could also be possible that their bias is unconscious and they may be unable to change it as they do not even realize they are doing it. The public stigma can affect how the mentally ill are treated in the justice system (ibid). People fear those with mental illness and they may be

Fraud, Waste and Abuse Research Project

3272 words - 13 pages Fraud, Waste and Abuse Research Project Combating fraud in the private sector is a difficult task. Trying to combat fraud in the public sector is daunting. In 1999 15.7% of the American workforce were employed by a government entity (federal, state, and local).[1] Mirroring society, government will have its share of perpetrators. The difference from the private sector is in the scope of the fraud committed, the loss of the public trust

IT System in Healthcare

855 words - 3 pages , laboratories, imaging services, geriatric wards, and many more. Thus, hospitals are an excellent representation of the healthcare system.Healthcare is an essential service which none of us can live without. Therefore, it is imperative that the system remains healthy and efficient. Over the past decade, information systems have played a vital role in upgrading healthcare systems across the globe. What once was a primitive and tedious paper and

Dricrimination of Women in the Family and in the Healthcare System

1021 words - 5 pages seriously or seen as equals to men and there can be a lot of pain from this. Doctors and the health care system hold a lot of power in this case. She had to do this visit or she might not get her Social Sercuirty check anymore and that is what she was living off of. The healthcare system need to be more aware of the people they have working for them because this women was sexually assaulted right in front of someone but no one wanted to take it

Importance of HIPAA and the Bill of Rights in the Healthcare System

1853 words - 7 pages Why is important for the HIPAA and the Bill of Right work in the healthcare system. Both the HIPAA and Bill of Right significance to the healthcare system all around the United State because of the strict guideline that were implemented to make the healthcare facilities a better place; for both patients and healthcare officials. These two laws that have been implemented, they have been the corner stone for many years

The New Healthcare System

1954 words - 8 pages be handed out to the public, however the plan is already in motion and cannot be stopped, although most have considered the good and the bad, most have found it unappealing. Many people are asking the question: is Obamacare the new health care system our country deserves or is it going to lead Americans into another economic downfall? For year’s government officials have been striving for better-cheaper healthcare and president Obama

The Healthcare Delivery System

1340 words - 6 pages care system. The patient-centred healthcare is the health care that is designed and delivered to meet the health care needed of the patient to ensure cost-effectiveness. In the 21st century, patient centred care have come up with the implementation of the infrastructural changes such as the electronic health records. The electronic health record will be patient-centred if it strengthens the patient clinician relationship by promoting the

The American Healthcare System

971 words - 4 pages about five hundred dollars or more thats wat they couldn’t pay. They tried many different ways to come up with money but every time they found a way it will never enough for pay the medical bills. The reasoning behind “health care reform” is the different health care reforms an analysis of inefficiencies and market failures in the current healthcare system. This could also explain the different things about the reforms and what they apply to

System Development, Management Controls and Fraud Prevention

2627 words - 11 pages that the product or system results in a system that meets the operational needs of the user. Validation is used to predict faults and gaps that might lead to invalid or incomplete verification of the product. This is mainly an external process. Security controls are to minimise or avoid security risks to any company or property; there are a number of ways to avoid this such as user login and access controls, firewalls and antivirus software

Quality of Care in the U.S. Healthcare Delivery System - Franklin University; Healthcare Management 735 - Essay

2243 words - 9 pages . To be effective, TQM must be an enterprise-or-organization-wide program beginning with C-suite management. All systems must be continuously evaluated and modified to achieve and maintain consistently high-quality services (Chakravarty et al. 2001). In the healthcare setting, Avedis Donabedian, MD, MPH was one of the first to recognize health care delivery as a system.  As a system, Dr. Donabedian postulated that the delivery of healthcare

Similar Essays

Cigarette Smoking And The Healthcare System In France

3902 words - 16 pages Structure France is regarded as a benchmark of healthcare delivery. Many countries are looking to France for answers to their healthcare challenges. In France, everyone has healthcare and the wait for services is not delayed, as some would believe. There is government-sponsored and private insurance. Their healthcare system is considered pluralistic because private and public entities exist together. Patients are free to choose physicians and

Infant Mortality In The Philippine Healthcare System

1507 words - 7 pages do not have the means or finances to seek assistance. This cycle of disparity has not only led to the loss of a person’s basic human right, but has also affected the livelihood of their children. This paper specifically outlines infant mortality rates in the Philippines, the populations at risk, risk factors surrounding this disparity, provider and nursing roles related to the Philippines healthcare delivery system, as well as strategies to help

Electronic Records In The Healthcare System

747 words - 3 pages record is stored in a server and can be accessed through the internet. In conclusion, EHRs and correlating systems, such as MC4, altered healthcare administration along with patient care. These systems have made transferring records more reliable, improved continuity of patient care, decreased record storage facilities and personnel, and diminished the amount of errors that occurred with paper documentation and records. The healthcare system is ever evolving and will continue to do so making patient care better than the days before.

Interview Report: Leadership In The Healthcare System

2469 words - 10 pages report concludes with a comparison and discussion of the results of the clinical condition on the basis of the interview and literature review. At the same time, the report aims to put forward feasible and effective advice and specific programs for present and future leaders and managers in the health care system. Methodology 1. The respondent’s traits and characteristics This is a nearly 40-minute interview. The object of this interview