Today, health care fraud is all over the news. There surely is fraud in medical care. The exact same is true for each business or endeavor touched by human hands, e.g. banking, credit, insurance, politics, etc.. There’s absolutely not any question that health care providers who misuse their position and our hope to steal are an issue. So are those from different professions that do the same.
Why does health care fraud seem to acquire the’lions-share’ of focus? Could it be that it’s the best vehicle to push agendas for divergent groups where taxpayers, medical care consumers and medical care providers are dupes in a medical care fraud shell-game worked with’sleight-of-hand’ precision?
Have a closer look and one finds out this isn’t any game-of-chance. Taxpayers, consumers and suppliers always lose because the issue with health care fraud isn’t merely the fraud, but it’s that our government and insurers utilize the fraud problem to further agendas while at the same time fail to be accountable and take responsibility for a fraud issue they ease and allow to flourish more info helseprodukter.org.
1. Astronomical Cost Estimates
What better way to report on fraud then to tout fraud cost estimates, e.g.
-“Fraud committed against both public and private health programs costs between $72 and $220 billion annually, increasing the cost of health care and health insurance and undermining public confidence in our medical care system… It’s not a secret that fraud represents one of the fastest growing and most costly types of crime in America now… We cover these prices as taxpayers and through higher health insurance premiums… We have to be proactive in combating health care fraud and abuse… We should also make certain that law enforcement has the resources that it needs to deter, detect, and punish medical 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 annually – or anywhere between 3% and 10% of the $2 trillion health care funding. [Health Care Finance News reports, 10/2/09] The GAO is the investigative arm of Congress.
– The National Health Care Anti-Fraud Association (NHCAA) reports over $54 billion is stolen each year in scams designed to adhere us and our insurance companies with fraudulent and illegal medical charges. [NHCAA, web-site] NHCAA was made and is funded by medical insurance companies.
Unfortunately, the trustworthiness of the supposed quotes is doubtful at best. Insurers, federal and state agencies, and others might gather fraud data associated with their own assignments, where the sort, quality and quantity of information compiled varies widely. David Hyman, professor of Law, University of Maryland, informs us that the widely-disseminated estimates of the incidence of health care fraud and abuse (assumed to be 10 percent of total spending) lacks any empirical basis in any respect, the little we do know about medical care fraud and abuse is dwarfed by what we do not know and that which we know that’s not so. [The Cato Journal, 3/22/02]
2. Health Care Standards
The laws & rules governing health care – differ from state to state and from payor to payor – are extensive and very confusing for suppliers and others to understand since they’re written in legalese rather than plain talk.
Providers use specific codes to report conditions treated (ICD-9) and services rendered (CPT-4 and HCPCS). These codes are used when seeking compensation from payors for services rendered to individuals. Though created to universally apply to facilitate accurate reporting to reflect providers’ services, many insurers educate providers to report codes based on what the insurer’s computer editing programs recognize – not on what the provider left. Further, practice construction consultants instruct providers on what codes to report to get paid – in some cases codes which don’t accurately reflect the supplier’s service.
Consumers understand what services they get from their physician or other provider but may not have a clue about what those billing codes or service descriptors mean on explanation of benefits received from insurance. This lack of understanding may lead to consumers moving on without getting clarification of exactly what the codes mean, or may lead to some thinking they were improperly billed. The great number of insurance programs available now, with varying amounts of policy, ad a wild card into the equation when services are denied for non-coverage – particularly if it is Medicare that denotes non-covered services as not medically necessary.
3. Proactively addressing the health care fraud Issue
The authorities and insurance companies do very little to address the issue with tangible activities that will bring about detecting inappropriate claims before they are paid. Really, payors of health care claims purport to run a payment system based on trust that providers bill correctly for services rendered, as they can’t review each claim before payment is made because the reimbursement system would shut down.
They claim to use complex computer programs to search for mistakes and patterns in claims, have improved pre- and post-payment audits of selected providers to detect fraud, and have generated consortiums and task forces comprising law enforcers and insurance investigators to examine the issue and share fraud info. But this action, for the most part, is addressing action after the claim is paid and has little bearing on the proactive detection of fraud.