Health Care Fraud – The Perfect Storm

Today, health care fraud is all above the news. Presently there undoubtedly is fraud in health care. Precisely the same is true for each and every business or project touched by human hands, e. g. banking, credit, insurance, politics, and so forth There is no question that physicians who abuse their position and our trust of taking are a problem. Thus are those from other professions who the genuine same.

Why does health care fraud appear to get the ‘lions-share’ of attention? Could it be that it is the perfect vehicle to drive agendas for divergent teams where taxpayers, health attention consumers and health health care providers are dupes in a health care scams shell-game operated with ‘sleight-of-hand’ precision? 

Take a deeper look and one detects this is not a game-of-chance. Taxpayers, consumers and providers always lose because the condition with health attention fraud is not merely the fraud, but it is that our government and insurers use the scams problem to increase agendas while at the same time fail to be responsible and take responsibility for a fraud problem they facilitate and allow to flourish.

1. Astronomical Expense Estimates

What better way to report on fraudulence then to tout scam cost estimates, e. g.

– “Fraud perpetrated against both public and private health plans costs between $72 and $220 billion dollars annually, increasing the expense of medical care and health and wellness14911 weakening public trust in our overall health care system… It is not anymore a secret that fraud represents one of the speediest growing and most costly kinds of criminal offenses in America today… We all pay these costs as taxpayers and through higher health insurance premiums… We need to be proactive in dealing with health care fraud and abuse… We must also ensure that law adjustment has the tools that this needs to deter, identify, and punish health health care fraud. ” [Senator Ted Kaufman (D-DE), 10/28/09 press release]

– The General Accounting Office (GAO) estimates that fraud in healthcare ranges from $60 billion to $600 billion dollars per year – or anywhere between 3% and 10% of the $2 trillion health care budget. [Health Care Financing News reports, 10/2/09] The GAO is the investigative arm of The legislature.

– The National Wellness Care Anti-Fraud Association (NHCAA) reports over $54 billion dollars is stolen annually in scams made to stick all of us and our insurance companies with fraudulent and against the law medical charges. [NHCAA, web-site] NHCAA was created and is financed by health insurance companies.

Unfortunately, the reliability of the purported estimates is dubious best case situation. Insurers, state and federal government agencies, and more may accumulate fraud data related to their own missions, where the kind, quality and volume of data put together varies widely. David Hyman, professor of Law, University or college of Maryland, tells all of us that the widely-disseminated estimations of the incidence of health care fraud and abuse (assumed to be 10% of total spending) lacks any empirical base at all, the little we know about health care fraud and mistreatment is dwarfed in what we don’t know and whatever we know that is not so. [The Cato Journal, 3/22/02]

2. Wellness Care Standards

The laws and regulations & rules governing health care – vary from state to state and from payor to payor – are intensive and very confusing for providers and others to understand because they are written in legalese and never basic speak.

Providers use specific codes to report conditions treated (ICD-9) and services rendered (CPT-4 and HCPCS). These codes are being used when seeking compensation from payors for services rendered to patients. Although developed to globally apply to facilitate exact reporting to reflect providers’ services, many insurers teach providers to report limitations based on what the insurer’s computer editing programs recognize – not on what the provider delivered. Further, practice building sales staff instruct providers on what codes to are responsible to get paid – sometimes codes that do not accurately reflect the provider’s service.

Consumers really know what services they receive from their doctor or other provider but might not exactly have a clue as to what those billing rules or service descriptors suggest on explanation of benefits received from insurers. This kind of lack of understanding may bring about consumers moving on without gaining clarification of the particular codes mean, or may bring about some thinking we were holding improperly billed. The great number of insurance plans available today, with varying levels of coverage, ad a wild card to the equation when services are denied for non-coverage – particularly if it is Treatment that denotes non-covered services as not medically necessary.

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