HEALTH CARE FRAUD

Imagine being sick with something other than the flu or a common cold. Not knowing what is wrong with your body you call your most trusted physician in desperation. Upon your visit to the doctor you receive a two minute consultation that ends with the diagnosis of a disease that you are not familiar with. You are prescribed pain pills and medications. After a few days on the medication you are feeling worse causing you to call again for advice; and they then explain that you are experiencing severe side effects and schedule you for a follow up appointment. At that time you are prescribed alternate medications for your ailment and the same thing occurs. At what point do you stop calling your trusted physician for help? How would you feel if you saw another doctor who told you that there was no disease? If this scenario fits your life-style then you may be a victim of health care fraud. There is only one definition of the term, many signs of being a victim, and a group that is usually targeted in a scheme called health care fraud.

The government has only recently started its battle against health care fraud. In 1986 the first mention of health care fraud surfaced as the “Federal False Claims Act” (FCA); which states that any person that reports to “an officer or employee of the United States Government or a member of Armed Forces of the United States a false or fraudulent claim for payment or approval…is liable to the United States Government to pay for a civil penalty of no less than $5,000 and not more than $10,000, plus 3 times the amount of damages that are sustained because of the act of the person”. The Act was to be a cure to health care fraud which is the treatment of “ghost patients, upcoding, unbundling, and billing for unnecessary care”. Ghost patients are the people that the physicians claim to have treated but never existed or are deceased; they can also be names and information of people who are obtained through identity theft. The word upcoding refers to the billing for services that were rendered at a higher cost than the procedure or prescription entails. Unbundling is the billing for each procedure thoroughly as if each were different. Lastly billing for unnecessary care can range from falsifying treatments to prescribing treatments or medications that are not needed. The legislation did not work as a solvent to the problem of health care fraud but it is believed to be working as a deterrent. The extremely high numbers we are seeing in victims, restitution, and physicians involved in this activity are the proactive efforts of the government on schemes that have been brewing for years.

The media shows the felons that are being caught now and it giving the misperception that numbers of people being violated by health care fraud are drastically increasing and this was true in prior years. Between the years of 1995-2003 the nation saw a 7 percent decrease in pay to physicians. It was during that time that we started to see a rise in the amount of health care fraud. In fact according to the Anti-Fraud Resource Center there were more than 4 billion health care claims processed in 2007 totaling $2.26 trillion. These amounts of claims filed have a 3-10 percent fraud rate that totals between $68-$226 billion. Although this percentage seems small we can see in the dollar value the large amount of deficit. This is a lot of wasted tax dollars being spent on white-collar crime among one of the highest paying professions available. It is because of health care fraud that others are forced to pay higher premiums and out-of-pocket expenses.

One of the most horrific schemes of health care fraud recalled is a team of 3 physicians and a hospital administrator that would victimize elderly, homeless, and drug abusers for profit. These physicians were caught in 2002 after they had already made victims of approximately 750 people over a ten year span. This is only one incident that was found in a single year, and health care fraud has been happening for over two decades. They would captivate their victim’s attention through bribery such as: food, money, and cigarettes; and once they had them they would fictitiously diagnose them of symptoms by running tests that involved sticking needles into these people’s hearts.

They benefited from this practice by reporting to insurance agencies such as: Medical and Medicaid the procedures that had been done for compensation. Two people lost their lives due to this malpractice, but others were damaged physically and financially. The leader of the pack is now serving 12 ½ years in federal prison and facing approximately 12 million in restitution fees, and the others are currently serving time for their participation. There are many other stories like this one of small medical offices providing services for feign ailments just so that they can reap the benefits. It used to be easy for this type of practices to sneak through the wires because the practices were so small and there are many different insurance agencies for these places to report to. Doctor’s in most cases are a person’s saving grace as they have studied how to treat unbearable discomfort and pain. Greed and corruption is ruining the nations trust in medical practice. As we can see the motive for the actions of these people who originally studied medicine to help people has been purely demoralization due to greed, and in turn may be desperation in a deteriorating economy.

Most of the cases have the same victim profile: the elderly, homeless, and drug abusers. The reason for this is that the elderly are weak and an easy prey; plus most of their testimonies (if ever brought to court) will not stand due to memory loss, or enhanced illnesses. The homeless do not usually have access to health care so this makes it easy to accept any diagnosis for an issue that is being experienced. The drug abusers are also an easy target because they will fill any prescription that is given to them time and time again. Each time they fill a prescription this is revenue for the physician who prescribed it as they file claim to insurance agencies. The targets are of different age groups, but all the same in the aspect that they don’t have many resources, need medical attention, and are gullible to any prognosis.

In response to health care fraud congress passed new legislation and an anti-fraud organization was established. According to National Health Care Anti-Fraud Association (NHCAA) congress passed the “Health Insurance Portability and Accountability Act of 1996…which specifically established health care fraud as a federal criminal offense”. The penalties for this offense is the eligibility of a federal prison term of up to ten years with a plausible separate charge and sentence for anyone who was harmed physically due to the malpractice with a maximum of 20 years, and if a patient died due to negligence the perpetrator may become a lifer. The “Coordinated Fraud and Abuse Control Program” was also born from health care fraud and allows federal and state law enforcement to share information with private health insurers. The NHCAA is a non-profit organization that specializes in aiding efforts in the private and public sectors in the detection, investigation, prosecution, and prevention of health care fraud. The government is still fighting the battle against health care fraud but if we continue to follow the investigations we can see that most of these schemes have developed over time. The best way to aid in the battle is to: treat your health identification card like a credit card, be informed, read your policy, and most importantly report fraud when you suspect that you are a victim of it.

Works Cited

Association, N. H.-F. (2010). The Problem of Health Care Fraud. Retrieved June 4, 2010, from Anti-Fraud Resource Center: http://www.nhcaa.org/eweb/DynamicPage.aspx?webcode=anti_fraud_resource_centr&wpscode=TheProblemOfHCFraud

Centers for Medicaid and Medicare Services. (n.d.). Retrieved July 4, 2010, from US Department of Health and Human Services: http://www.cms.gov/smdl/downloads/SMD032207Att2.pdf

Health Care Statistics. (2010, July). Retrieved July 4, 2010, from HealthCareProblems.org: http://www.healthcareproblems.org/health-care-statistics.htm

Johnson, C. (2007, July 19). U.S. Targets Health-Care Fraud, Abuse. Retrieved July 4,2010, from The Washington Post: http://www.washingtonpost.com/wp-dyn/content/article/2007/07/18/AR2007071802461.html?hpid=sec-business

Levinson, H. (2010, December 26). What is Healthcare Fraud? Retrieved June 4, 2010, from Examiner.com: http://www.examiner.com/x-33884-St-Louis-Health-Insurance-Examiner~y2009m12d26-Healthcare-FraudYoure-Getting-Ripped-Off

Slade, S. R. (2000). Health Care Fraud: How far does the False Claims Act reach? Retrieved July 4, 2010, from Quackwatch: http://www.quackwatch.org/02ConsumerProtection/fca.html