Healthcare fraud and abuse Essays

Healthcare fraud and abuse Essays Healthcare fraud and abuse Paper Healthcare fraud and abuse Paper As a Denzel Washington fan, I remembered a movie a couple of years back with a relation to health care entitled John Q.   It depicts a man undergoing hardships to get his son a heart transplant because his HMO would not cover it due to his employee status. Although the plot did not center on health care per se, it got me thinking about how far my own HMO coverage would go. This paper aims to tackle 3 types of abuse and fraud in healthcare in order to prevent and direct much needed resources to those deserving. Along with the advances that we have achieved come those with ill-intent out to further themselves hence health care fraud and abuse.   This is defined in Qui Tam FYI as, â€Å"deceptive means used by an organization to profit from government healthcare agreements. That definition has more recently been extended to include not only deception, but also unreasonable ignorance of the rules.† In 1985, to combat the growing threats against this criminal activity, the NHCAA or National Health Care Antifraud Association was established and has turned to become the leading American organization directed towards health insurance fraud. Their mission statement: â€Å"To protect and serve the public interest by increasing awareness and improving the detection, investigation, civil and criminal prosecution and prevention of health care fraud.†3   Ã‚  We go on to discuss the different type of fraud and abuse. The most rampant is the misrepresentation of goods and services.   A concrete example is when someone is treated for a common cold but when forwarded to the HMO it would appear that the patient was tested for pneumonia and a full blood test was conducted when no such activity was done. The hospital or clinic would then receive compensation for something which was fictitious.   A simple way to prevent this would be to confirm with the person examined unless they were in on it too. Another is padding the costs of medical services and medicines.   Purchase prices for medicine are sometimes marked up 200% onwards under the guise of increased cost. With services however, the modus operandi is billing for each separate exam rather than the comprehensive package therefore increasing the total price.   Both instances would increase revenues while maintaining overhead costs. Lastly, some institutions recommend treatment or exams which are unnecessary.   They plague on people’s fears and tell them it is better safe than to be sorry.   The difference between this example and the first one is that the tests actually took place.   It was just not needed.   In the person suffering from the cold example, a doctor could say that he needs to go through a battery of tests in order to eliminate other possibilities when the symptoms shown were very negligible or unfounded. Healthcare fraud and abuse is covered in the United States by the Federal False Claims Act.   This law protects victims and with penalties like fines and in sever cases even prison sentences.   It provides that any citizen can on the behalf of the government, file a case against companies or persons engaged in misrepresented activities and also protects that citizen from legal repercussions. Medical insurance companies also hire independent auditors and investigators to validate the claims made by clients and establishments to defend against potential loss from swindlers. â€Å"In 2003, health care costs paid to hospitals, physicians, nursing homes, diagnostic laboratories, pharmacies, medical device manufacturers and other components of the health care system, consumed 26.3 percent of the GDP of the United States, the largest of any country in the whole wide world.† That amount of money will attract people with ill-intent who always try to make a quick buck.   This will be a continuing fight from organizations like the NHCAA and governments who want to make sure that persons who deserve medical assistance will always get it. Reference List World Health Organization Report. (2000). Why do health systems matter?   WHO Qui Tam FYI.   â€Å"What is health care fraud?† retrieved 9 March 2008 from quitamfyi.com/healthcare-fraud.html National Health Care Antifraud Association.   Mission Statement retrieved 9 March 2008 from nhcaa.org/eweb/DynamicPage.aspx?webcode=about_nhcaawpscode=WhoWeAre Wikipedia article on health care.   (2008) â€Å"Health Care† retrieved 9 March 2008