Health Care Fraud – The Perfect Storm

Today, the headlines about health care fraud. Undoubtedly, there is fraud in the health sector. The same goes for any business or business that is touched by human hands, such as banking, credit, insurance, politics, etc. This also applies to other professionals who do the same.

Why is medical fraud attracting attention? Could this be an ideal tool for managing the agendas of various groups in which taxpayers, health care providers and health care providers are being tricked into the shell of health-care fraud by “gimmicks?”?

Take a closer look and you’ll notice that it’s not a gamble. Taxpayers, consumers and service providers always lose because the problem of health care fraud is not only fraud, but also our government and insurers use the problem of fraud to prosecute their claims. Programs without taking responsibility and not taking responsibility for the fraud problem. Bloom.

  1. Astronomical cost estimate

What better way to report fraud than to specify an estimate of the cost of fraud, for example.

“Public and private health plans are worth between $72 billion and $220 billion a year, increasing the cost of health care and health insurance and undermining public confidence in our health care system.” It is no longer a secret that fraud is the fastest growing and most expensive crime in America today… We pay these costs as taxpayers and by raising premiums. Health insurance … We must actively fight fraud and abuse in the health sector … We must act this also to ensure that law enforcement agencies have the tools they need to prevent, detect and punish health care fraud. “Senator Ted Kaufman (Germany), press release dated 28.10.09

The National Association Against Health Fraud (NHCAA) reports that more than $54 billion is stolen each year as part of a fraud aimed at attacking us and our insurance companies with fraudulent and illegal medical bills. “NHCAA, website” NHCAA was founded and funded by insurance companies.

Unfortunately, the reliability of the intended estimates is questionable at best. Insurers, state and federal agencies, and others can collect fraud data related to their own tasks, and the type, quality and volume of data collected vary greatly. David, a law professor at the University of Maryland, tells us that widespread estimates of health fraud and abuse (which are supposed to account for 10% of total costs) have no empirical basis for how little we know about it. Health fraud and abuse are overshadowed by what we do not know and do not know. [The Cato Journal, 22.03.02]

  1. Health standards

Health care laws and regulations – vary from state to state and from payer to payer – are common and very confusing for health care providers and others because they are written in legal language rather than plain language.

Providers use special codes to report treatment conditions (CIM-9) and services provided (CPT-4 and HCPCS). These codes are used to seek compensation from payers for services provided to patients. While universally applicable to provide accurate reporting that reflects provider services, many insurers require providers to report codes based on what they recognize the insurer’s computer operating programs, not what the insurer’s provider is. Train construction consultants to tell vendors more about which codes should be reported to receive payment – in some cases codes that don’t accurately reflect the provider’s services.

Consumers know what services they receive from their doctor or other provider, but may not know what these billing codes or service descriptions mean when explaining the benefits they have received from insurers.

  1. Actively combating the problem of health-care fraud.

The government and insurers do little to proactively address the problem with real-world action that leads to the discovery of irregular claims before they are paid. The payers of insurance reimbursements do claim to use a payment system based on the trust that suppliers accurately bill the services provided, as they cannot evaluate each claim before payment, as the reimbursement system will be closed.

They say they use sophisticated computer programs to find errors and patterns in complaints, have stepped up prepayment and postpaid some vendors to detect fraud and have set up consortiums and task teams of investigators for law enforcement and insurance problems. . and share information about fraud. However, these activities are mainly due to post-payment and have little effect on pre-emptive fraud detection.

  1. Control health fraud through new laws.

Government reports on fraud are published in earnest along with efforts to reform our health care system, and our experience shows that this ultimately leads to the government passing new laws – provided that new laws lead to the detection, investigation and investigation of more cases of fraud. prosecuted by law – without determining whether the new laws would be more effective than existing laws that were not used optimally.

As a result of these efforts, we received the Health Insurance Portability and Accountability Act (HIPAA) in 1996. It was passed by Congress to address the issue of portability of insurance and liability for patient privacy, as well as fraud and abuse in the health care sector.

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