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...

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