According to the World Health Organization health care cost in 2008, cost 5.7 trillion dollars and 7.29% of that were due to fraud. In the United States $2 trillion is spent annually on health care and out of that 60 billion is money lost by fraud. (CCH® BENEFITS — 02/12/10) Health care could have put that money to a better use.
Illegal drug dealing
Eastern Kentucky, according to an AP report out today (2-2-2012) is full of fraudulent pill peddlers. “If something isn’t done the whole area will be destroyed” a Floyd County attorney is quoted as having said. The problem isn’t localized it’s all over the country: Recently a Kansas judge sentenced two offenders in prison for 30 and 33 years. These documented cases, investigated for over four years, showed that at least 100 hundred emergency room visits for overdosing resulted in 68 deaths.
What determines fraud
Ways in which health care providers—and yes consumers—abuse the system is incalculable and while this needs be curtailed, it isn’t termed fraud. Fraud is a deliberate act to gain money illegally from health care funds and other health resource providers. Claims can be filed for services not rendered; forging signatures on prescription blanks; altering bills or receipts; using someone else’s insurance card are a few of the ways evil doers line their pockets with money not theirs.
Real cases being tried in court and sentenced are too numerous to mention but recently a federal judge in Birmingham, Alabama sentenced a hospice provider with illegally gaining 3 billion from Medicare; another illegal operator of five half-ways houses in Fort Lauderdale, Florida (Orlando Sentinel) was convicted on a kickback scheme. He referred his residents, mostly recovering alcoholics and drug users, to a fraudulent health care provider. Health care fraud knows no boundaries
Health care fraud is not one sided. Consumers, as well as providers are guilty, although consumers are less likely to be charged or convicted. When they use their health insurance card to purchase items or medicine or ask for unnecessary procedures they don’t have to pay for, it’s illegal. Although it is low level abuse of the system they need be educated to the importance of protecting the system, not using it because it’s available. Likewise, they need not give in the persistent advertisements that tend to cloud the issues of real need versus a slight convenience.
But largely health care fraud is premeditated offenses against the health care system. It’s rampant in this country because private insurers and other citizens take advantage of private enterprise as opposed to a socialized form of medicine. In other systems the government controls every aspect of health care and there’s fewer ways health care can be corrupted. There’s also less incentive to get involved with one’s own personal health and not to leave it up to overworked systems that dole out health care as if it’s a scarce commodity.
Billing for services not rendered; falsifying diagnosis’ in order to justify expensive tests, surgeries or other unnecessary procedures; misrepresenting; accepting kickbacks; billing the patient when the co-pay amount has already been paid; unbundling or stretching a procedure out and billing for each phase as if it’s a separate procedure are also ways health care cost has hit the ceiling.
The remedy
The NHCAA (National Health Care Anti-fraud Association suggests that better communication between private insurers and the government; consolidation of data and how it’s interpreted; stronger reviews and audits; more flexibility in expelling offenders; more intense involvement by state licensing boards; better detection and more secure number identification systems would go a long ways toward preventing health care fraud.