Health Care Fraud – The Perfect Storm

Today, health care fraud is all above the news. Right now there undoubtedly is fraud in health care. Similar is true for each and every business or undertaking 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 piracy are a problem. Therefore are those from other professions who the real same. Elder care services

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 organizations where taxpayers, health treatment consumers and health attention providers are dupes in a health care scam shell-game operated with ‘sleight-of-hand’ precision? 

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

1. Astronomical Expense Estimates

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

– “Fraud perpetrated against both public and private health plans costs between $72 and $220 billion dollars annually, increasing the price tag on medical care and wellbeing and14911 weakening public trust in our overall health care system… It is no more a secret that fraud represents one of the most effective growing and most costly kinds of criminal offense in America today… We all pay these costs as taxpayers and through higher health insurance premiums… We need to be proactive in coping with health care fraud and abuse… We must also ensure that law adjustment has the tools it needs to deter, find, and punish health treatment 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 Our elected representatives.

– The National Overall health Care Anti-Fraud Association (NHCAA) reports over $54 billion dollars is stolen yearly in scams built to stick all of us and our insurance companies with fraudulent and illegitimate 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 circumstance. Insurers, state and federal government agencies, while others may collect fraud data related to their own missions, where the kind, quality and volume of data created varies widely. David Hyman, professor of Law, University or college of Maryland, tells all of us that the widely-disseminated quotes 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. Well being Care Standards

The laws and regulations & rules governing health care – vary from state to state and from payor to payor – are comprehensive and very confusing for providers and others to understand because they are written in legalese and never simple 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 generally apply to facilitate exact reporting to reflect providers’ services, many insurers advise 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 liable to get paid – occasionally codes that do not accurately reflect the provider’s service.

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